Provider Demographics
NPI:1457124786
Name:VAN ARSDALE, MARY GRACE
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:GRACE
Last Name:VAN ARSDALE
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 1:14138 CASTOR ST
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-2321
Mailing Address - Country:US
Mailing Address - Phone:512-517-5528
Mailing Address - Fax:
Practice Address - Street 1:14138 CASTOR ST
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-2321
Practice Address - Country:US
Practice Address - Phone:512-517-5528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT87327133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered