Provider Demographics
NPI:1619282324
Name:GRILLO, KORI L (LCSW)
Entity Type:Individual
Prefix:
First Name:KORI
Middle Name:L
Last Name:GRILLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 NE 33RD AVE APT 1C
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-7218
Mailing Address - Country:US
Mailing Address - Phone:646-647-7644
Mailing Address - Fax:
Practice Address - Street 1:2901 NE 33RD AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-7218
Practice Address - Country:US
Practice Address - Phone:646-647-7644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY8845161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health