Provider Demographics
NPI:1386028454
Name:LEVIN, TARA JEAN (MS, RD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JEAN
Last Name:LEVIN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 WALNUT ST APT 6
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-4553
Mailing Address - Country:US
Mailing Address - Phone:267-246-5964
Mailing Address - Fax:
Practice Address - Street 1:2301 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-3542
Practice Address - Country:US
Practice Address - Phone:215-952-9248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA86007432133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered