Provider Demographics
NPI:1073588463
Name:MCDERMOTT, TERESA LYNN (RD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:MCDERMOTT
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 1:7838 FALLING LEAF PL
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6424
Mailing Address - Country:US
Mailing Address - Phone:321-752-4599
Mailing Address - Fax:
Practice Address - Street 1:2900 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-8007
Practice Address - Country:US
Practice Address - Phone:321-637-3788
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
871506133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered