Provider Demographics
NPI:1598529620
Name:GROSSMAN, MIREL (RDN)
Entity Type:Individual
Prefix:
First Name:MIREL
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1473 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-5033
Mailing Address - Country:US
Mailing Address - Phone:718-715-9577
Mailing Address - Fax:
Practice Address - Street 1:1473 E 21ST ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-5033
Practice Address - Country:US
Practice Address - Phone:718-715-9577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2750695133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered