Provider Demographics
NPI:1730680109
Name:GRULLON, NICOLE (RBT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GRULLON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13000 SW 15TH CT APT 309U
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-2405
Mailing Address - Country:US
Mailing Address - Phone:305-213-1003
Mailing Address - Fax:
Practice Address - Street 1:11441 INTERCHANGE CIR S
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-6009
Practice Address - Country:US
Practice Address - Phone:305-573-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-17-46606106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician