Healthcare Provider Details

I. General information

NPI: 1053381822
Provider Name (Legal Business Name): DEIDRE E WILLIAMS NUTRITIONIST
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 CAMBRIDGE ST
BRIGHTON MA
02135-2907
US

IV. Provider business mailing address

77 WARREN ST 3RD FLOOR
BRIGHTON MA
02135-3601
US

V. Phone/Fax

Practice location:
  • Phone: 617-562-7132
  • Fax:
Mailing address:
  • Phone: 617-562-5413
  • Fax: 617-562-5415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number2381
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: