Provider Demographics
NPI:1851721997
Name:DOHM, THERESA (RD LD CNSC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:DOHM
Suffix:
Gender:F
Credentials:RD LD CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-0938
Mailing Address - Country:US
Mailing Address - Phone:417-396-0993
Mailing Address - Fax:
Practice Address - Street 1:1716 KANSAS AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-0938
Practice Address - Country:US
Practice Address - Phone:417-396-0993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007024809133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered