Provider Demographics
NPI:1285824276
Name:PERSOHN, CASEY C (RD)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:C
Last Name:PERSOHN
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 1:1314 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-2860
Mailing Address - Country:US
Mailing Address - Phone:812-254-2760
Mailing Address - Fax:812-257-8602
Practice Address - Street 1:300 NE 14TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-2137
Practice Address - Country:US
Practice Address - Phone:812-254-2250
Practice Address - Fax:812-254-7884
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN934562133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN941140K7Medicare PIN