Basic Information
| Provider Information | |||||||||
| NPI: | 1134229396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORESTA | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S GATE PARK | ||||||||
| Address2: | |||||||||
| City: | WEST NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024651616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179697661 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 732 HARRISON AVE | ||||||||
| Address2: | PRESTON FAMILY BLD, 2ND FL | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174148037 | ||||||||
| FaxNumber: | 6176387449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2188 | MA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 2188 | 01 | MA | LDN LICENSE NO | OTHER |