MEDICARE: KORI L GRILLO LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker	884516	NY

General Provider Information

NPI Number	:	1619282324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KORI L GRILLO LCSW

Provider Business Mailing Address
First Line	:	2901 NE 33RD AVE APT 1C
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-7218
Country	:	US
Telephone Number	:	646-647-7644
Fax Number	:

Provider Business Practice Location Address
First Line	:	2901 NE 33RD AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-7218
Country	:	US
Telephone Number	:	646-647-7644
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2010
Last Update Date	:	08/12/2021

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