Provider Demographics
NPI:1336403088
Name:GRODRIAN, MARTHA KAY (RD, LD, CDE, IBCLC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:KAY
Last Name:GRODRIAN
Suffix:
Gender:F
Credentials:RD, LD, CDE, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:953 GARDNER RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-4520
Mailing Address - Country:US
Mailing Address - Phone:937-293-0553
Mailing Address - Fax:937-641-2605
Practice Address - Street 1:953 GARDNER RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-4520
Practice Address - Country:US
Practice Address - Phone:937-293-0553
Practice Address - Fax:937-641-2605
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD656133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered