Provider Demographics
NPI:1154491058
Name:GILBERT, THERESA LYNN (RD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:GILBERT
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 1:1557 LANGDON DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE FINANCE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-5006
Mailing Address - Country:US
Mailing Address - Phone:937-648-6095
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGARMAPLE RD
Practice Address - Street 2:88 MEDICAL GROUP SGQD
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433
Practice Address - Country:US
Practice Address - Phone:937-257-9069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5857133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered