Provider Demographics
NPI:1043557143
Name:SGRULLONI, SHELLEY (BA)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:SGRULLONI
Suffix:
Gender:
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473 JORDAN STUART CIR APT 213
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-2427
Mailing Address - Country:US
Mailing Address - Phone:508-265-6543
Mailing Address - Fax:
Practice Address - Street 1:5959 LAKE ELLENOR DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4633
Practice Address - Country:US
Practice Address - Phone:407-490-1453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-49918103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS645783897570OtherDRIVER'S LICENSE