Provider Demographics
NPI:1093772014
Name:GRILL, KENNETH LLOYD (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LLOYD
Last Name:GRILL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22282 VISTA LAGO DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-4764
Mailing Address - Country:US
Mailing Address - Phone:561-362-8009
Mailing Address - Fax:
Practice Address - Street 1:7900 GLADES RD STE 230
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-4104
Practice Address - Country:US
Practice Address - Phone:561-488-7771
Practice Address - Fax:561-477-3634
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003910103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73711Medicare ID - Type Unspecified