Provider Demographics
NPI:1053672188
Name:BROOKS, SHIRLEY (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2777 N STEMMONS FWY STE 400
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75207-2265
Mailing Address - Country:US
Mailing Address - Phone:857-249-4780
Mailing Address - Fax:
Practice Address - Street 1:360 HUNTINGTON AVE
Practice Address - Street 2:208 RB
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5005
Practice Address - Country:US
Practice Address - Phone:857-249-4780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07342133V00000X
MA3308133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT07342OtherRD LICENSE
MA3308OtherREGISTERED DIETITIAN LICENSE