Provider Demographics
NPI:1639349947
Name:STEPHENSON, CHARLOTTE TIFFANY (MS RD LDN)
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:TIFFANY
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:MS RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 WASHINGTON STREET
Mailing Address - Street 2:CODMAN SQUARE HEALTH CENTER
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124
Mailing Address - Country:US
Mailing Address - Phone:617-822-8303
Mailing Address - Fax:617-288-7898
Practice Address - Street 1:637 WASHINGTON STREET
Practice Address - Street 2:CODMAN SQUARE HEALTH CENTER
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124
Practice Address - Country:US
Practice Address - Phone:617-822-8303
Practice Address - Fax:617-288-7898
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2649133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered