Provider Demographics
NPI:1669493029
Name:WITHEE, MARY T (RD, CDE)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:WITHEE
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 SIEGLER ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2635
Mailing Address - Country:US
Mailing Address - Phone:920-497-3126
Mailing Address - Fax:920-497-3176
Practice Address - Street 1:141 SIEGLER ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2635
Practice Address - Country:US
Practice Address - Phone:920-497-3126
Practice Address - Fax:920-497-3176
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
455439133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered