Provider Demographics
NPI:1275040842
Name:MARK, LEAH MARIE (MS, RD, CDN, CPT)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:MARIE
Last Name:MARK
Suffix:
Gender:F
Credentials:MS, RD, CDN, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 PLOVER LN
Mailing Address - Street 2:
Mailing Address - City:LLOYD HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11743-1037
Mailing Address - Country:US
Mailing Address - Phone:516-810-8808
Mailing Address - Fax:516-300-1492
Practice Address - Street 1:44 GREEN ST STE 2
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3393
Practice Address - Country:US
Practice Address - Phone:516-806-0045
Practice Address - Fax:516-861-0061
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008091133N00000X, 133NN1002X, 133VN1004X, 133VN1005X, 133VN1006X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Multi-Specialty
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic