Healthcare Provider Details

I. General information

NPI: 1316479827
Provider Name (Legal Business Name): ELIZABETH GINGOLD MATTEO M.S, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 COMMONWEALTH AVE 6TH FLOOR
BOSTON MA
02215-1605
US

IV. Provider business mailing address

635 COMMONWEALTH AVE 6TH FLOOR
BOSTON MA
02215-1605
US

V. Phone/Fax

Practice location:
  • Phone: 617-353-2721
  • Fax:
Mailing address:
  • Phone: 617-353-2721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number004277-NU-NU
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: