Provider Demographics
NPI:1679277149
Name:THACH, ELEANOR KATHRYN ERICKSON (MS, RDN)
Entity Type:Individual
Prefix:MRS
First Name:ELEANOR KATHRYN
Middle Name:ERICKSON
Last Name:THACH
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WORDEN AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-4031
Mailing Address - Country:US
Mailing Address - Phone:919-357-4544
Mailing Address - Fax:
Practice Address - Street 1:105 WORDEN AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-4031
Practice Address - Country:US
Practice Address - Phone:919-357-4544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1048912133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered