Healthcare Provider Details

I. General information

NPI: 1053938795
Provider Name (Legal Business Name): MICHELLE THOMAS BROWN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE T. GROSSMAN RD

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3508 S LIVE OAK DR
MONCKS CORNER SC
29461-8737
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-958-2590
  • Fax: 843-606-7996
Mailing address:
  • Phone: 888-472-0043
  • Fax: 843-724-2454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1982
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: