Provider Demographics
NPI:1629793401
Name:BUTTS, LYDIA ABIGAIL (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:ABIGAIL
Last Name:BUTTS
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 FULLER RD
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-7138
Mailing Address - Country:US
Mailing Address - Phone:318-510-6773
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-990-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3452133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered