Provider Demographics
NPI:1568565497
Name:GREEN, CYNTHIA K (ED DIETITIAN)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:K
Last Name:GREEN
Suffix:
Gender:F
Credentials:ED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N SARAH DEWITT DR
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-3311
Mailing Address - Country:US
Mailing Address - Phone:830-672-7581
Mailing Address - Fax:830-672-2401
Practice Address - Street 1:1110 N SARAH DEWITT DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-3311
Practice Address - Country:US
Practice Address - Phone:830-672-7581
Practice Address - Fax:830-672-2401
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX862948133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3460982Medicaid
TX00L70BOtherMEDICARE GROUP NUMBER
TX862948OtherDIETETIC REGISTRATION
TXDT05451OtherLICENSED DIETITIAN