Provider Demographics
NPI:1770772550
Name:DE LA SOUJEOLE, MARTHA (RD, LD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:DE LA SOUJEOLE
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 1:4100 W ELDORADO PKWY
Mailing Address - Street 2:SUITE 100, BOX 231
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-4422
Mailing Address - Country:US
Mailing Address - Phone:469-285-0636
Mailing Address - Fax:469-952-3687
Practice Address - Street 1:431 EAST STACY ROAD
Practice Address - Street 2:SUITE 107
Practice Address - City:FAIRVIEW
Practice Address - State:TX
Practice Address - Zip Code:75069-9496
Practice Address - Country:US
Practice Address - Phone:469-285-0636
Practice Address - Fax:469-952-3687
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80586133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered