Provider Demographics
NPI:1659500874
Name:DIAS, ELIZABETH LEACH (RD, LDN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LEACH
Last Name:DIAS
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 GOVERNORS AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-1643
Mailing Address - Country:US
Mailing Address - Phone:401-486-7747
Mailing Address - Fax:
Practice Address - Street 1:170 GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-1643
Practice Address - Country:US
Practice Address - Phone:781-306-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2749133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered