MEDICARE: ZOMELY GRULLON LCAT-LP, MA

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	P139094	NY

General Provider Information

NPI Number	:	1669327581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZOMELY GRULLON LCAT-LP, MA

Provider Business Mailing Address
First Line	:	62 BAINBRIDGE ST APT 2A
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11233-1742
Country	:	US
Telephone Number	:	914-885-4148
Fax Number	:

Provider Business Practice Location Address
First Line	:	6704 MYRTLE AVE STE 2080
Second Line	:
City	:	GLENDALE
State	:	NY
Zip	:	11385-7033
Country	:	US
Telephone Number	:	347-871-5931
Fax Number	:

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

Provider Enumeration Date	:	03/04/2026
Last Update Date	:	03/12/2026

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