Provider Demographics
NPI:1912753344
Name:GRILLO LEON, MAYARA
Entity Type:Individual
Prefix:
First Name:MAYARA
Middle Name:
Last Name:GRILLO LEON
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 1:26150 SW 137TH AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6987
Mailing Address - Country:US
Mailing Address - Phone:239-201-7451
Mailing Address - Fax:
Practice Address - Street 1:26150 SW 137TH AVE APT 205
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-6987
Practice Address - Country:US
Practice Address - Phone:239-201-7451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-312892106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician