Provider Demographics
NPI:1780976126
Name:EUSTACE, KATHLEEN A (RD LD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:EUSTACE
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:A
Other - Last Name:BREWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LD
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-5722
Mailing Address - Fax:214-645-7501
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390
Practice Address - Country:US
Practice Address - Phone:214-645-5722
Practice Address - Fax:214-645-7501
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81625133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered