Provider Demographics
NPI:1467568113
Name:SROUFEK, BROOKE HEATHER (MS,RD,LD)
Entity Type:Individual
Prefix:MISS
First Name:BROOKE
Middle Name:HEATHER
Last Name:SROUFEK
Suffix:
Gender:F
Credentials:MS,RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 892
Mailing Address - Street 2:
Mailing Address - City:CATLIN
Mailing Address - State:IL
Mailing Address - Zip Code:61817-0892
Mailing Address - Country:US
Mailing Address - Phone:217-304-5102
Mailing Address - Fax:
Practice Address - Street 1:1900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5100
Practice Address - Country:US
Practice Address - Phone:217-554-5801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered