Provider Demographics
NPI:1083378582
Name:GRINO, RENE GAPASIN JR
Entity Type:Individual
Prefix:MR
First Name:RENE
Middle Name:GAPASIN
Last Name:GRINO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2718 RIVER OAK DR
Mailing Address - Street 2:
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1439
Mailing Address - Country:US
Mailing Address - Phone:702-722-9451
Mailing Address - Fax:
Practice Address - Street 1:555 WALTON RD
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-1538
Practice Address - Country:US
Practice Address - Phone:850-892-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH21690101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health