Provider Demographics
NPI:1588839948
Name:MONG, BETH ANN (RD CD)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:MONG
Suffix:
Gender:F
Credentials:RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 TATEAM DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-9384
Mailing Address - Country:US
Mailing Address - Phone:317-745-5891
Mailing Address - Fax:765-779-4010
Practice Address - Street 1:751 TATEAM DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-9384
Practice Address - Country:US
Practice Address - Phone:317-745-5891
Practice Address - Fax:765-779-4010
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001813A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN37001813AOtherINDIANA RD CERTIFICATION
IN200881730OtherFIRST STEPS LPI