Provider Demographics
NPI:1922117654
Name:ANDERSON, MARYLOU (CD)
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 E SENECA ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4214
Mailing Address - Country:US
Mailing Address - Phone:206-957-1666
Mailing Address - Fax:206-325-2689
Practice Address - Street 1:1002 E SENECA ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4214
Practice Address - Country:US
Practice Address - Phone:206-957-1666
Practice Address - Fax:206-325-2689
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000830133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered