Healthcare Provider Details

I. General information

NPI: 1508255142
Provider Name (Legal Business Name): CARLY GONET RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 MAIN ST SUITE 910
WORCESTER MA
01608-1604
US

IV. Provider business mailing address

264 GLEASONDALE RD
STOW MA
01775-1337
US

V. Phone/Fax

Practice location:
  • Phone: 978-727-4762
  • Fax:
Mailing address:
  • Phone: 978-727-4762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3524
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: