Provider Demographics
NPI:1053819037
Name:SMITH, LISA GEBAUER (RD,CDN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GEBAUER
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD,CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 E ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-4800
Mailing Address - Country:US
Mailing Address - Phone:716-694-5112
Mailing Address - Fax:
Practice Address - Street 1:111 MAIN ST
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-3718
Practice Address - Country:US
Practice Address - Phone:716-438-4031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR577673133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered