Provider Demographics
NPI:1114234085
Name:MOUTRAY, BRITTNEY L (RD LDN CDE)
Entity Type:Individual
Prefix:
First Name:BRITTNEY
Middle Name:L
Last Name:MOUTRAY
Suffix:
Gender:F
Credentials:RD LDN CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 WEST ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-2757
Mailing Address - Country:US
Mailing Address - Phone:815-780-3560
Mailing Address - Fax:815-780-4679
Practice Address - Street 1:241 W WEAVER RD
Practice Address - Street 2:SUITE 210
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535
Practice Address - Country:US
Practice Address - Phone:217-876-5370
Practice Address - Fax:217-876-5375
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005188133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered