Provider Demographics
NPI:1225592736
Name:PHILLIP, SUSAN K (NDTR)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:K
Last Name:PHILLIP
Suffix:
Gender:F
Credentials:NDTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2404
Mailing Address - Country:US
Mailing Address - Phone:617-233-4950
Mailing Address - Fax:
Practice Address - Street 1:67 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-2404
Practice Address - Country:US
Practice Address - Phone:617-233-4950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 174H00000X
1018812136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No174H00000XOther Service ProvidersHealth Educator