Provider Demographics
NPI:1942320999
Name:LEBEAU, MARY LYNN (RD,LD,CDE)
Entity Type:Individual
Prefix:MS
First Name:MARY LYNN
Middle Name:
Last Name:LEBEAU
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 1:895 SOMERTON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6203
Mailing Address - Country:US
Mailing Address - Phone:314-205-6483
Mailing Address - Fax:
Practice Address - Street 1:232 S WOODS MILL RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3417
Practice Address - Country:US
Practice Address - Phone:314-205-6483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001017857133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO077685Medicare ID - Type UnspecifiedDIETITIAN PROVIDER