Healthcare Provider Details

I. General information

NPI: 1851562821
Provider Name (Legal Business Name): MARY BETH HANEY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 SW 7TH ST
TOPEKA KS
66606-2489
US

IV. Provider business mailing address

415 CEDAR ST
LYNDON KS
66451-9552
US

V. Phone/Fax

Practice location:
  • Phone: 785-295-8146
  • Fax: 785-295-8194
Mailing address:
  • Phone: 785-828-3218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1017
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: