Provider Demographics
NPI:1083639132
Name:GRILL, ALLAN (CRC, MFT)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:
Last Name:GRILL
Suffix:
Gender:M
Credentials:CRC, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201C ZAFARANO DR # 300
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-2668
Mailing Address - Country:US
Mailing Address - Phone:510-232-1630
Mailing Address - Fax:
Practice Address - Street 1:3201C ZAFARANO DR # 300
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2668
Practice Address - Country:US
Practice Address - Phone:510-232-1630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 24930106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist