Healthcare Provider Details

I. General information

NPI: 1629167853
Provider Name (Legal Business Name): MICHELLE M RAYMOND RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

967 CHESTNUT ST
NEWTON MA
02464-1101
US

V. Phone/Fax

Practice location:
  • Phone: 857-218-4766
  • Fax:
Mailing address:
  • Phone: 856-218-4766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number2280
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: