Basic Information
Provider Information | |||||||||
NPI: | 1083842116 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GREAT LAKES DIETARY COUNSELING, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 36151 MORAVIAN DR | ||||||||
Address2: |   | ||||||||
City: | CLINTON TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 480351148 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5862915669 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 36151 MORAVIAN DR | ||||||||
Address2: |   | ||||||||
City: | CLINTON TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 480351148 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5862915669 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2009 | ||||||||
LastUpdateDate: | 07/28/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAMPASONA | ||||||||
AuthorizedOfficialFirstName: | JOSEFINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | REGISTERED DIETITIAN | ||||||||
AuthorizedOfficialTelephone: | 5862915669 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MS, RD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | 947399 |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.