Provider Demographics
NPI:1508300237
Name:DAUM, MICHELLE (MS, RD)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:DAUM
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-4003
Mailing Address - Country:US
Mailing Address - Phone:914-834-0483
Mailing Address - Fax:
Practice Address - Street 1:54 BEACH AVE
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-4003
Practice Address - Country:US
Practice Address - Phone:914-834-0483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002423133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered