Provider Demographics
NPI:1346575263
Name:GRENNELL, MATTHEW (BCABA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GRENNELL
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 BENT OAK LOOP
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-5791
Mailing Address - Country:US
Mailing Address - Phone:321-356-4759
Mailing Address - Fax:407-699-0444
Practice Address - Street 1:225 S SWOOPE AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5704
Practice Address - Country:US
Practice Address - Phone:407-928-0444
Practice Address - Fax:407-699-0444
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst