Provider Demographics
NPI:1073185864
Name:CARBALLO, GRETTEL (LMHC)
Entity Type:Individual
Prefix:
First Name:GRETTEL
Middle Name:
Last Name:CARBALLO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17302 NW 63RD PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4468
Mailing Address - Country:US
Mailing Address - Phone:786-437-3710
Mailing Address - Fax:
Practice Address - Street 1:17302 NW 63RD PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-4468
Practice Address - Country:US
Practice Address - Phone:786-437-3710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MH19055101Y00000X
103K00000X
FLMH19055101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MH19055OtherLMHC