Provider Demographics
NPI:1689443871
Name:GRULLON, PATRICIA M (LMFT)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:GRULLON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 SW 30TH PL
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33315-2733
Mailing Address - Country:US
Mailing Address - Phone:305-975-6064
Mailing Address - Fax:
Practice Address - Street 1:1503 SW 30TH PL
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33315-2733
Practice Address - Country:US
Practice Address - Phone:305-975-6064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT4623106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist