Healthcare Provider Details

I. General information

NPI: 1295433290
Provider Name (Legal Business Name): SOPHIA TIBERI MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/20/2023
Certification Date: 02/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

429 W 4TH ST
SOUTH BOSTON MA
02127-2653
US

V. Phone/Fax

Practice location:
  • Phone: 781-343-3198
  • Fax:
Mailing address:
  • Phone: 781-343-3198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: