Provider Demographics
NPI:1881865558
Name:ELISBERG, TERRI P (RD,LD,CDE)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:P
Last Name:ELISBERG
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 998
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059
Mailing Address - Country:US
Mailing Address - Phone:505-450-9961
Mailing Address - Fax:
Practice Address - Street 1:47 VILLACITOS RD
Practice Address - Street 2:
Practice Address - City:TIJERAS
Practice Address - State:NM
Practice Address - Zip Code:87059-6601
Practice Address - Country:US
Practice Address - Phone:505-450-9961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM059133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM059OtherLICENSE