Provider Demographics
NPI:1790957546
Name:GROBE, CARRIE C (MS,RD)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:C
Last Name:GROBE
Suffix:
Gender:F
Credentials:MS,RD
Other - Prefix:MS
Other - First Name:CARRIE
Other - Middle Name:C
Other - Last Name:CASSENS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:211 S JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:POLO
Mailing Address - State:IL
Mailing Address - Zip Code:61064-1719
Mailing Address - Country:US
Mailing Address - Phone:815-222-4236
Mailing Address - Fax:
Practice Address - Street 1:211 S JACKSON AVE
Practice Address - Street 2:
Practice Address - City:POLO
Practice Address - State:IL
Practice Address - Zip Code:61064-1719
Practice Address - Country:US
Practice Address - Phone:815-222-4236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
IL164002838133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164002838OtherILLINOIS LICENSE