Provider Demographics
NPI:1669761904
Name:ALDERSON, SUSAN (RD,CDE)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ALDERSON
Suffix:
Gender:F
Credentials:RD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5325 FARAON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3488
Mailing Address - Country:US
Mailing Address - Phone:816-271-6700
Mailing Address - Fax:816-271-6701
Practice Address - Street 1:5325 FARAON ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3488
Practice Address - Country:US
Practice Address - Phone:816-271-6700
Practice Address - Fax:816-271-6701
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001003607133V00000X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1669761904Medicaid
MO701000240Medicare PIN