Provider Demographics
NPI:1124430616
Name:GRULLON, MARINA
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:GRULLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 MCGRAW AVE
Mailing Address - Street 2:6H
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-7976
Mailing Address - Country:US
Mailing Address - Phone:646-323-9827
Mailing Address - Fax:
Practice Address - Street 1:135 EINSTEIN LOOP
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-4974
Practice Address - Country:US
Practice Address - Phone:718-320-3082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program