Healthcare Provider Details

I. General information

NPI: 1386806107
Provider Name (Legal Business Name): BRENDA SUE DEBORD M.A.,R.D.,L.D.,C.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ZORN AVE
LOUISVILLE KY
40206-1433
US

IV. Provider business mailing address

7216 HILL PARK WAY APT. 256
LOUISVILLE KY
40220-7155
US

V. Phone/Fax

Practice location:
  • Phone: 502-287-4513
  • Fax:
Mailing address:
  • Phone: 502-458-3510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberKY-0595
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: