Provider Demographics
NPI:1982411260
Name:BLYLEVEN, GRACIE (RBT)
Entity type:Individual
Prefix:
First Name:GRACIE
Middle Name:
Last Name:BLYLEVEN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3045 N COMMERCE PKWY
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 ROBERTS CUT OFF RD
Practice Address - Street 2:
Practice Address - City:RIVER OAKS
Practice Address - State:TX
Practice Address - Zip Code:76114-2825
Practice Address - Country:US
Practice Address - Phone:817-731-2293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-24-398163106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician