Healthcare Provider Details

I. General information

NPI: 1881002707
Provider Name (Legal Business Name): KATHERINE GLICK R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST BLVD
ELKHART IN
46514-2483
US

IV. Provider business mailing address

600 EAST BLVD
ELKHART IN
46514-2499
US

V. Phone/Fax

Practice location:
  • Phone: 260-433-4890
  • Fax:
Mailing address:
  • Phone: 574-389-4827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86001709
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: