Provider Demographics
NPI:1447392089
Name:HARDY, MARY BLACKARD (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BLACKARD
Last Name:HARDY
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 1:924 ROSE CRYSTAL WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-2398
Mailing Address - Country:US
Mailing Address - Phone:817-250-5417
Mailing Address - Fax:817-250-5136
Practice Address - Street 1:1301 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2122
Practice Address - Country:US
Practice Address - Phone:817-250-5417
Practice Address - Fax:817-250-5417
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT00336133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered