Basic Information
Provider Information | |||||||||
NPI: | 1891463501 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROOKS | ||||||||
FirstName: | CECILY | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD, LDN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1859 SHARWOOD PL | ||||||||
Address2: |   | ||||||||
City: | CROFTON | ||||||||
State: | MD | ||||||||
PostalCode: | 211141949 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2024313023 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 354 MOUNTAIN RD STE G | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | MD | ||||||||
PostalCode: | 211221158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4102557200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2021 | ||||||||
LastUpdateDate: | 08/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DX5423 | MD | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.