Healthcare Provider Details

I. General information

NPI: 1831419373
Provider Name (Legal Business Name): LUCINDA MARIA BALSOME M.S.,R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 KELSEY LN
GLASTONBURY CT
06033-5015
US

IV. Provider business mailing address

62 KELSEY LN
GLASTONBURY CT
06033-5015
US

V. Phone/Fax

Practice location:
  • Phone: 860-796-4160
  • Fax:
Mailing address:
  • Phone: 860-796-4160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number000080
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number720769
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: