Provider Demographics
NPI:1184787970
Name:VAN DUSEN, LISA C (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:VAN DUSEN
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 RADFORD RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MA
Mailing Address - Zip Code:01541-1806
Mailing Address - Country:US
Mailing Address - Phone:978-464-5307
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-856-2492
Practice Address - Fax:508-856-8020
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA575133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered