Provider Demographics
NPI:1124507520
Name:COSME GRULLON, JOSE ENRIQUE
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:ENRIQUE
Last Name:COSME GRULLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12124 CALABOOSE CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8977
Mailing Address - Country:US
Mailing Address - Phone:939-358-7056
Mailing Address - Fax:
Practice Address - Street 1:3201 BUDINGER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-7203
Practice Address - Country:US
Practice Address - Phone:407-891-3054
Practice Address - Fax:888-477-7678
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
PR11418104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator