Provider Demographics
NPI:1750916573
Name:GAVIRIA, GRECIA A
Entity type:Individual
Prefix:
First Name:GRECIA
Middle Name:A
Last Name:GAVIRIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 WASHINGTON AVE APT 3A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-5491
Mailing Address - Country:US
Mailing Address - Phone:732-232-8501
Mailing Address - Fax:
Practice Address - Street 1:465 GRAND ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4800
Practice Address - Country:US
Practice Address - Phone:732-232-8501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001914103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst