Provider Demographics
NPI:1750907267
Name:LAVERY, HEATHER (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:LAVERY
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 BOYLSTON ST STE 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-4825
Mailing Address - Country:US
Mailing Address - Phone:203-610-4928
Mailing Address - Fax:
Practice Address - Street 1:665 BOYLSTON ST STE 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-4825
Practice Address - Country:US
Practice Address - Phone:203-610-4928
Practice Address - Fax:857-350-3251
Is Sole Proprietor?:No
Enumeration Date:2020-06-20
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5085-NU-NU133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty