Provider Demographics
NPI:1912157660
Name:SARAH GLEASON REGISTERED DIETITIAN
Entity Type:Organization
Organization Name:SARAH GLEASON REGISTERED DIETITIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GLEASON
Authorized Official - Suffix:
Authorized Official - Credentials:RD LD
Authorized Official - Phone:636-978-6901
Mailing Address - Street 1:103 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-1603
Mailing Address - Country:US
Mailing Address - Phone:636-978-6901
Mailing Address - Fax:
Practice Address - Street 1:103 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-1603
Practice Address - Country:US
Practice Address - Phone:636-978-6901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005008318133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty