Provider Demographics
NPI:1730670290
Name:SELF, LAURA L (RDN, LD)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:L
Last Name:SELF
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NAVIGATOR DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-4938
Mailing Address - Country:US
Mailing Address - Phone:214-415-7630
Mailing Address - Fax:
Practice Address - Street 1:100 NAVIGATOR DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-4938
Practice Address - Country:US
Practice Address - Phone:214-415-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81191133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered