Provider Demographics
NPI:1942672167
Name:TEVIS, MOLLY CAY (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:CAY
Last Name:TEVIS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:CAY
Other - Last Name:MCINTYRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:520 S EAGLE RD
Mailing Address - Street 2:SUITE 1223
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6351
Mailing Address - Country:US
Mailing Address - Phone:208-706-5260
Mailing Address - Fax:208-706-5152
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:SUITE 1223
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-706-5260
Practice Address - Fax:208-706-5152
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD687133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered