Healthcare Provider Details

I. General information

NPI: 1255180931
Provider Name (Legal Business Name): MELISSA SYBERTZ MS RD CSO LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE
BOSTON MA
02215-5400
US

IV. Provider business mailing address

107 STETSON ST
WHITMAN MA
02382-2474
US

V. Phone/Fax

Practice location:
  • Phone: 781-453-7580
  • Fax:
Mailing address:
  • Phone: 508-649-4092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License Number4862
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: