Provider Demographics
NPI:1043557143
Name:SGRULLONI, SHELLEY (BA)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:SGRULLONI
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5372
Mailing Address - Country:US
Mailing Address - Phone:407-490-1453
Mailing Address - Fax:
Practice Address - Street 1:523 WEKIVA COMMONS CIR # 4
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-3645
Practice Address - Country:US
Practice Address - Phone:407-464-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-15-6915106E00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS645783897570OtherDRIVER'S LICENSE