Provider Demographics
NPI:1457198848
Name:GRILLO ALEJO, CARMEN LUISA
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:LUISA
Last Name:GRILLO ALEJO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14524 DUNROBIN DR
Mailing Address - Street 2:
Mailing Address - City:WIMAUMA
Mailing Address - State:FL
Mailing Address - Zip Code:33598-6182
Mailing Address - Country:US
Mailing Address - Phone:813-328-0798
Mailing Address - Fax:
Practice Address - Street 1:14524 DUNROBIN DR
Practice Address - Street 2:
Practice Address - City:WIMAUMA
Practice Address - State:FL
Practice Address - Zip Code:33598-6182
Practice Address - Country:US
Practice Address - Phone:813-328-0798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-360516106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty