Provider Demographics
NPI:1932730033
Name:GRABER, KONNOR (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:KONNOR
Middle Name:
Last Name:GRABER
Suffix:
Gender:M
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3139 S GARRISON CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-9229
Mailing Address - Country:US
Mailing Address - Phone:812-929-2212
Mailing Address - Fax:
Practice Address - Street 1:1711 N COLLEGE AVE STE 101
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-2450
Practice Address - Country:US
Practice Address - Phone:812-929-2212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-19-37373103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst