Provider Demographics
NPI:1942505516
Name:SUMMERLIN, MARY-BLAKE HARBIN (RD)
Entity Type:Individual
Prefix:MRS
First Name:MARY-BLAKE
Middle Name:HARBIN
Last Name:SUMMERLIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23256 WILD DAISY WAY
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-4186
Mailing Address - Country:US
Mailing Address - Phone:410-412-4994
Mailing Address - Fax:
Practice Address - Street 1:24035 THREE NOTCH RD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:MD
Practice Address - Zip Code:20636-4871
Practice Address - Country:US
Practice Address - Phone:301-373-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3157133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered