Provider Demographics
NPI:1093096075
Name:LE, KATHERINE THUY TIEN (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:THUY TIEN
Last Name:LE
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 1:14 COMMONWEALTH CT
Mailing Address - Street 2:#16
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-4538
Mailing Address - Country:US
Mailing Address - Phone:904-294-3028
Mailing Address - Fax:
Practice Address - Street 1:230 BOWDOIN ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-1817
Practice Address - Country:US
Practice Address - Phone:617-754-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3171133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered