Healthcare Provider Details

I. General information

NPI: 1093535585
Provider Name (Legal Business Name): SUSAN MARSHALL RD, CSPCC, CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13123 E 16TH AVE # 270
AURORA CO
80045-7106
US

IV. Provider business mailing address

5628 S QUATAR CT
CENTENNIAL CO
80015-6005
US

V. Phone/Fax

Practice location:
  • Phone: 720-777-4902
  • Fax:
Mailing address:
  • Phone: 530-400-2557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1401X
TaxonomyPediatric Critical Care Nutrition Registered Dietitian
License Number966480
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number966480
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: