Provider Demographics
NPI:1295446193
Name:MOUNTASER, HEBA (RD,LD)
Entity type:Individual
Prefix:
First Name:HEBA
Middle Name:
Last Name:MOUNTASER
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12105 WALDEN WOOD DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5573
Mailing Address - Country:US
Mailing Address - Phone:507-202-8376
Mailing Address - Fax:
Practice Address - Street 1:12105 WALDEN WOOD DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5573
Practice Address - Country:US
Practice Address - Phone:507-202-8376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT87578133V00000X
TX86171843133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered