Basic Information
| Provider Information | |||||||||
| NPI: | 1235719212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOFIDI | ||||||||
| FirstName: | SHIDEH | ||||||||
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| Credential: | MS, RD, CSP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 MARTLING AVE | ||||||||
| Address2: | |||||||||
| City: | PLEASANTVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105703132 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 19 BRADHURST AVE STE 2850S | ||||||||
| Address2: | |||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9143045280 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2021 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1004X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric | 133VN1006X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.