Provider Demographics
NPI:1033314315
Name:CRISCIONE, TERASA (RD)
Entity Type:Individual
Prefix:
First Name:TERASA
Middle Name:
Last Name:CRISCIONE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 PHEASANT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LOUDONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12211-1524
Mailing Address - Country:US
Mailing Address - Phone:518-588-6920
Mailing Address - Fax:
Practice Address - Street 1:578 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4024
Practice Address - Country:US
Practice Address - Phone:518-588-6920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered