Provider Demographics
NPI:1962906362
Name:WYLIE, GREGORY RAYMOND (BCBA, LABA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:RAYMOND
Last Name:WYLIE
Suffix:
Gender:M
Credentials:BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MAIN ST APT C
Mailing Address - Street 2:
Mailing Address - City:BUZZARDS BAY
Mailing Address - State:MA
Mailing Address - Zip Code:02532-3264
Mailing Address - Country:US
Mailing Address - Phone:339-236-0734
Mailing Address - Fax:
Practice Address - Street 1:47 E GROVE ST STE 102
Practice Address - Street 2:
Practice Address - City:MIDDLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02346-1816
Practice Address - Country:US
Practice Address - Phone:800-679-3609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALABA10000434103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst