Provider Demographics
NPI:1033687355
Name:GRILLO, LISA ELAINE (SUDP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ELAINE
Last Name:GRILLO
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 S PLUM ST STE A
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-4539
Mailing Address - Country:US
Mailing Address - Phone:206-441-3043
Mailing Address - Fax:206-442-4155
Practice Address - Street 1:2120 S PLUM ST STE A
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-4539
Practice Address - Country:US
Practice Address - Phone:206-441-3043
Practice Address - Fax:206-442-4155
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00000455101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)