Provider Demographics
NPI:1114390085
Name:PHILLY DIETITIAN LLC
Entity Type:Organization
Organization Name:PHILLY DIETITIAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:SHANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-203-9728
Mailing Address - Street 1:1909 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3244
Mailing Address - Country:US
Mailing Address - Phone:717-203-9728
Mailing Address - Fax:
Practice Address - Street 1:1909 GREEN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-3244
Practice Address - Country:US
Practice Address - Phone:717-203-9728
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004553133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty