Provider Demographics
NPI:1356773683
Name:VIVRETT, MARY ELLEN (RD, LD)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:VIVRETT
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 1:3725 LONG AVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-4728
Mailing Address - Country:US
Mailing Address - Phone:409-651-3489
Mailing Address - Fax:409-899-0448
Practice Address - Street 1:3725 LONG AVE
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-4728
Practice Address - Country:US
Practice Address - Phone:409-651-3489
Practice Address - Fax:409-898-0448
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT02946133NN1002X
TX16160133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16160OtherREGISTERED DIETITIAN
TXDT02946OtherLICENSED DIETITIAN