Provider Demographics
NPI:1417236811
Name:HUBLITZ, LISA M (RD, LD, CDE, CSP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:HUBLITZ
Suffix:
Gender:F
Credentials:RD, LD, CDE, CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5138 KLAMATH CT SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-1503
Mailing Address - Country:US
Mailing Address - Phone:503-363-4002
Mailing Address - Fax:
Practice Address - Street 1:5138 KLAMATH CT SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-1503
Practice Address - Country:US
Practice Address - Phone:503-363-4002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR803182133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric