Healthcare Provider Details

I. General information

NPI: 1437438645
Provider Name (Legal Business Name): IVIS THEODORE FORRESTER PH.D., RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 REISTERSTOWN RD
BALTIMORE MD
21251
US

IV. Provider business mailing address

6210 GLEN FALLS RD
REISTERSTOWN MD
21136
US

V. Phone/Fax

Practice location:
  • Phone: 410-367-7821
  • Fax: 410-367-7823
Mailing address:
  • Phone: 410-833-3682
  • Fax: 410-833-3682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD02016
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberD02016
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: