Provider Demographics
NPI:1386735165
Name:GRELLA, ROBERT (LISW)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:GRELLA
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5312 JAGUAR DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-1827
Mailing Address - Country:US
Mailing Address - Phone:505-820-0262
Mailing Address - Fax:505-820-9220
Practice Address - Street 1:5312 JAGUAR DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-1827
Practice Address - Country:US
Practice Address - Phone:505-820-0262
Practice Address - Fax:505-820-9220
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI 056611041C0700X
NY0737911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM97720321Medicaid