Provider Demographics
NPI:1356573661
Name:GROTHEER, SHIRLEY B (LD)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:B
Last Name:GROTHEER
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 MIDDLE MARSH RETREAT
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31411-2602
Mailing Address - Country:US
Mailing Address - Phone:912-598-0150
Mailing Address - Fax:
Practice Address - Street 1:315 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2605
Practice Address - Country:US
Practice Address - Phone:912-354-4687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000731133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered