Provider Demographics
NPI:1740543198
Name:GRULLON, ERICA
Entity type:Individual
Prefix:
First Name:ERICA
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 1:4019 79TH ST
Mailing Address - Street 2:1D
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1159
Mailing Address - Country:US
Mailing Address - Phone:212-821-9538
Mailing Address - Fax:
Practice Address - Street 1:4019 79TH ST
Practice Address - Street 2:1D
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1159
Practice Address - Country:US
Practice Address - Phone:212-821-9538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator