Provider Demographics
NPI:1467017293
Name:KERBS, CASEY (RDN, CDN)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:KERBS
Suffix:
Gender:F
Credentials:RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 RILEY AVE
Mailing Address - Street 2:
Mailing Address - City:MATTITUCK
Mailing Address - State:NY
Mailing Address - Zip Code:11952-1804
Mailing Address - Country:US
Mailing Address - Phone:631-275-2370
Mailing Address - Fax:
Practice Address - Street 1:1455 OLD SHIPYARD LN
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-1539
Practice Address - Country:US
Practice Address - Phone:631-275-2370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1099557133V00000X
NY009080133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered