Healthcare Provider Details

I. General information

NPI: 1952396871
Provider Name (Legal Business Name): MARY TRAHAN LIVELY LDN, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 HIGHWAY 609
DELHI LA
71232-6563
US

IV. Provider business mailing address

309 JACKSON ST
MONROE LA
71201-7407
US

V. Phone/Fax

Practice location:
  • Phone: 318-878-6760
  • Fax:
Mailing address:
  • Phone: 318-327-4973
  • Fax: 318-327-4975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number858
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: