Provider Demographics
NPI:1972186260
Name:RUPP, GREGORY THOMAS (MM, MT-BC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:THOMAS
Last Name:RUPP
Suffix:
Gender:M
Credentials:MM, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-2009
Mailing Address - Country:US
Mailing Address - Phone:631-873-7407
Mailing Address - Fax:
Practice Address - Street 1:10 NEW KARNER RD
Practice Address - Street 2:
Practice Address - City:GUILDERLAND
Practice Address - State:NY
Practice Address - Zip Code:12084-9578
Practice Address - Country:US
Practice Address - Phone:410-804-0439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
14638225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist