Provider Demographics
NPI:1649346412
Name:CERRATE-REINOSO, LICIA MARLENE (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:LICIA
Middle Name:MARLENE
Last Name:CERRATE-REINOSO
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:NUTRICIA
Other - Middle Name:DIETETIC
Other - Last Name:CONSULTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LLC
Mailing Address - Street 1:1400 E RIDGE RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78503-1535
Mailing Address - Country:US
Mailing Address - Phone:956-928-0400
Mailing Address - Fax:956-928-0411
Practice Address - Street 1:1400 E RIDGE RD
Practice Address - Street 2:SUITE 7
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1535
Practice Address - Country:US
Practice Address - Phone:956-928-0400
Practice Address - Fax:956-928-0411
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-25
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07623133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178780601Medicaid