Provider Demographics
NPI:1023101441
Name:GRELLONG, JO BARRETT (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JO
Middle Name:BARRETT
Last Name:GRELLONG
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 1:205 W 89TH ST
Mailing Address - Street 2:APT. 11G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-1828
Mailing Address - Country:US
Mailing Address - Phone:212-595-1788
Mailing Address - Fax:212-875-8797
Practice Address - Street 1:205 W 89TH ST
Practice Address - Street 2:APT 11G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-1838
Practice Address - Country:US
Practice Address - Phone:212-595-1788
Practice Address - Fax:212-875-8797
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR014231-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0062504OtherGHI-VALUE OPTIONS
NYP45646Medicare UPIN
NY0062504OtherGHI-VALUE OPTIONS