Healthcare Provider Details

I. General information

NPI: 1326511940
Provider Name (Legal Business Name): OLIVIA HAEBERLE RD/LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4113 DANIEL GREEN TRL SE
SMYRNA GA
30080-6310
US

IV. Provider business mailing address

4113 DANIEL GREEN TRL SE
SMYRNA GA
30080-6310
US

V. Phone/Fax

Practice location:
  • Phone: 404-312-2131
  • Fax:
Mailing address:
  • Phone: 404-312-2131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number002719
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number002719
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number002719
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number002719
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number002719
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number002719
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number002719
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number002719
License Number StateGA
# 9
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number002719
License Number StateGA
# 10
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number002719
License Number StateGA
# 11
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number002719
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: