Provider Demographics
NPI:1396193397
Name:HEIDT, CHARLEEN M (RD)
Entity Type:Individual
Prefix:MS
First Name:CHARLEEN
Middle Name:M
Last Name:HEIDT
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 1:107 W FALLS ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3212
Mailing Address - Country:US
Mailing Address - Phone:607-227-5954
Mailing Address - Fax:
Practice Address - Street 1:107 W FALLS ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3212
Practice Address - Country:US
Practice Address - Phone:607-227-5954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY396146133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered