Healthcare Provider Details

I. General information

NPI: 1336412394
Provider Name (Legal Business Name): BARBARA GROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8955 GUILFORD RD SUITE 240
COLUMBIA MD
21046-2651
US

IV. Provider business mailing address

1321 BLUEGRASS WAY
GAMBRILLS MD
21054-1052
US

V. Phone/Fax

Practice location:
  • Phone: 443-393-2650
  • Fax:
Mailing address:
  • Phone: 240-476-5091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX3072
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: