Provider Demographics
NPI:1477215697
Name:MCCOURT, KELSEY MARIE (RDN)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:MCCOURT
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 VICTORIA AVE UNIT 101
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-5758
Mailing Address - Country:US
Mailing Address - Phone:702-553-5579
Mailing Address - Fax:
Practice Address - Street 1:2598 MAIN ST
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1553
Practice Address - Country:US
Practice Address - Phone:805-225-7302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86074251133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered