Provider Demographics
NPI:1265024046
Name:OVERBECK, CAROL RENEE
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:RENEE
Last Name:OVERBECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 KATHRYN DR STE D
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-4200
Mailing Address - Country:US
Mailing Address - Phone:800-972-0643
Mailing Address - Fax:
Practice Address - Street 1:105 KATHRYN DR STE D
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-4200
Practice Address - Country:US
Practice Address - Phone:800-972-0643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07590133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered