Provider Demographics
NPI:1043958002
Name:BROOKS, MARY RACHEL (RDN, LD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RACHEL
Last Name:BROOKS
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-2211
Mailing Address - Country:US
Mailing Address - Phone:214-498-1366
Mailing Address - Fax:
Practice Address - Street 1:3802 HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-2211
Practice Address - Country:US
Practice Address - Phone:214-498-1366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85031133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86117172OtherCOMMISSION ON DIETETIC REGISTRATION