Provider Demographics
NPI:1841395068
Name:CARTY, CHANDRA BIVENS (RD,LD)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:BIVENS
Last Name:CARTY
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 BRUSHY NOB LN
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5243
Mailing Address - Country:US
Mailing Address - Phone:770-389-0836
Mailing Address - Fax:770-389-0886
Practice Address - Street 1:1516 ROCK QUARRY RD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5047
Practice Address - Country:US
Practice Address - Phone:770-389-0836
Practice Address - Fax:770-389-0886
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000618133V00000X, 133VN1004X, 133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA691002664AMedicaid