Provider Demographics
NPI:1235945452
Name:THEODORAKOS, BROOKE MARIE (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:MARIE
Last Name:THEODORAKOS
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 IRONHORSE CT
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-4676
Mailing Address - Country:US
Mailing Address - Phone:314-324-6119
Mailing Address - Fax:
Practice Address - Street 1:1145 IRONHORSE CT
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-4676
Practice Address - Country:US
Practice Address - Phone:314-324-6119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009000717133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered