Provider Demographics
NPI:1265997795
Name:GROTHMAN, BRANDI DAWN
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:DAWN
Last Name:GROTHMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 S PEAR LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7814
Mailing Address - Country:US
Mailing Address - Phone:662-820-5233
Mailing Address - Fax:
Practice Address - Street 1:1606 S PEAR LN
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7814
Practice Address - Country:US
Practice Address - Phone:662-820-5233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer