Provider Demographics
NPI:1053938795
Name:BROWN, MICHELLE THOMAS (RD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:THOMAS
Last Name:BROWN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:T
Other - Last Name:GROSSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:888-472-0043
Mailing Address - Fax:843-724-2454
Practice Address - Street 1:3508 S LIVE OAK DR
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-8737
Practice Address - Country:US
Practice Address - Phone:843-958-2590
Practice Address - Fax:843-606-7996
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1982133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDT1193Medicaid