Provider Demographics
NPI:1912406331
Name:BURGESS, EMILIE SJOSTROM (MS, RDN, LDN)
Entity Type:Individual
Prefix:MS
First Name:EMILIE
Middle Name:SJOSTROM
Last Name:BURGESS
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 1:213 FARMHOLME RD
Mailing Address - Street 2:
Mailing Address - City:STONINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06378-2205
Mailing Address - Country:US
Mailing Address - Phone:860-857-8153
Mailing Address - Fax:
Practice Address - Street 1:3 BOW ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5109
Practice Address - Country:US
Practice Address - Phone:617-547-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA86058869133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered