Provider Demographics
NPI:1740678945
Name:ELY, CATHERINE LEAH (RDN, LD)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:LEAH
Last Name:ELY
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:LEAH
Other - Last Name:MILLBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LD
Mailing Address - Street 1:305 NE LOOP 820
Mailing Address - Street 2:BUSINESS TOWER 1, SUITE 200
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-7209
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:920 SHILOH ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703
Practice Address - Country:US
Practice Address - Phone:903-939-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83400133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered