MEDICARE: RICHIE REBOLIOS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	625923941	NY

General Provider Information

NPI Number	:	1386596773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHIE REBOLIOS

Provider Business Mailing Address
First Line	:	22 BROADHOLLOW RD STE 402
Second Line	:
City	:	MELVILLE
State	:	NY
Zip	:	11747-2516
Country	:	US
Telephone Number	:	631-385-7780
Fax Number	:

Provider Business Practice Location Address
First Line	:	1311 MAMARONECK AVE STE 150
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10605-5222
Country	:	US
Telephone Number	:	914-328-2868
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2026
Last Update Date	:	02/10/2026

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