Provider Demographics
NPI:1295951143
Name:SANSEVERO, MARA ROSE (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:ROSE
Last Name:SANSEVERO
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S HUNTINGTON AVE
Mailing Address - Street 2:BRIGHAM & WOMEN'S ADVANCED PRIMARY CARE ASSOCIATES, SH
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4807
Mailing Address - Country:US
Mailing Address - Phone:857-307-3364
Mailing Address - Fax:
Practice Address - Street 1:301 S HUNTINGTON AVE
Practice Address - Street 2:BRIGHAM & WOMEN'S ADVANCED PRIMARY CARE ASSOCIATES, SH
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-4807
Practice Address - Country:US
Practice Address - Phone:857-307-3364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2140133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q35062Medicare UPIN
MAMT0745Medicare ID - Type Unspecified