Provider Demographics
NPI:1467942722
Name:STEVENSON, LISA JOHNSON (RD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JOHNSON
Last Name:STEVENSON
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 1:125 LASALLE RD STE 208
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2311
Mailing Address - Country:US
Mailing Address - Phone:860-906-1289
Mailing Address - Fax:860-906-1289
Practice Address - Street 1:1131 WEST ST STE 2
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-6006
Practice Address - Country:US
Practice Address - Phone:860-517-8888
Practice Address - Fax:860-426-2551
Is Sole Proprietor?:No
Enumeration Date:2018-05-12
Last Update Date:2018-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001610133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered