Provider Demographics
NPI:1760405880
Name:GRILLO, NICHOLAS JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:GRILLO
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12610 DONEGAL DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-3110
Mailing Address - Country:US
Mailing Address - Phone:804-744-8400
Mailing Address - Fax:804-790-1533
Practice Address - Street 1:4920 MILLRIDGE PKWY E
Practice Address - Street 2:SUITE 212
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4857
Practice Address - Country:US
Practice Address - Phone:804-744-8400
Practice Address - Fax:804-790-1533
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040007581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8901066Medicaid