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General NPI Number Information
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NPI Number | 1760405880
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Entity Type | Individual
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Provider Name | NICHOLAS GRILLO JR. LCSW
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Gender | Male
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Dates
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Enumeration Date | 07/26/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4920 MILLRIDGE PKWY E SUITE 212
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City | MIDLOTHIAN
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State | VA
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Zip | 23112-4857
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Country | US
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Telephone | 804-744-8400
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Fax | 804-790-1533
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Provider Business Mailing Address
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Address Line | 12610 DONEGAL DR
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City | CHESTERFIELD
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State | VA
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Zip | 23832-3110
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Country | US
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Telephone | 804-744-8400
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Fax | 804-790-1533
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0904000758
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License Number State | VA
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