Provider Demographics
NPI:1205950698
Name:WEIS-SCHUPAK, TERESA DANYELA (RD, CDN)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:DANYELA
Last Name:WEIS-SCHUPAK
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1805
Mailing Address - Country:US
Mailing Address - Phone:516-295-1186
Mailing Address - Fax:
Practice Address - Street 1:375 BROADWAY
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1805
Practice Address - Country:US
Practice Address - Phone:516-295-1186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0005217133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered