Provider Demographics
NPI:1619365624
Name:MCDERMOTT, CHRISTINE (MS, RD, CDE, CDN)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:MS, RD, CDE, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2752
Mailing Address - Country:US
Mailing Address - Phone:631-740-9330
Mailing Address - Fax:631-207-8414
Practice Address - Street 1:21 W 2ND ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2752
Practice Address - Country:US
Practice Address - Phone:631-740-9330
Practice Address - Fax:631-207-8414
Is Sole Proprietor?:No
Enumeration Date:2014-12-27
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY800283133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002315-1OtherNYS CDN LICENCE