Provider Demographics
NPI:1649017047
Name:GRELLO, DIANA BEACH
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:BEACH
Last Name:GRELLO
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 1:2684 SEQUOIA TER
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-6561
Mailing Address - Country:US
Mailing Address - Phone:631-835-9262
Mailing Address - Fax:
Practice Address - Street 1:2684 SEQUOIA TER
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-6561
Practice Address - Country:US
Practice Address - Phone:631-835-9262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000467-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health