Healthcare Provider Details

I. General information

NPI: 1619449899
Provider Name (Legal Business Name): ADI TOVA WYSHOGROD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 BARRY RD
WORCESTER MA
01609-1138
US

IV. Provider business mailing address

265 CHELMSFORD ST STE 7
CHELMSFORD MA
01824-2335
US

V. Phone/Fax

Practice location:
  • Phone: 508-736-5453
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86110390
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: