Provider Demographics
NPI:1326511940
Name:HAEBERLE, OLIVIA (RD/LD)
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:
Last Name:HAEBERLE
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4113 DANIEL GREEN TRL SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6310
Mailing Address - Country:US
Mailing Address - Phone:404-312-2131
Mailing Address - Fax:
Practice Address - Street 1:4113 DANIEL GREEN TRL SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6310
Practice Address - Country:US
Practice Address - Phone:404-312-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002719133NN1002X, 133VN1005X, 133VN1006X, 174200000X, 261QE0700X, 261QH0100X, 261QP0904X, 282E00000X, 282N00000X, 405300000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No174200000XOther Service ProvidersMeals
No261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
No282E00000XHospitalsLong Term Care Hospital
No282N00000XHospitalsGeneral Acute Care Hospital
No405300000XOther Service ProvidersPrevention Professional