Healthcare Provider Details

I. General information

NPI: 1447520770
Provider Name (Legal Business Name): THERESA STAHL RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12501 WILLOWBROOK RD WOC 2ND FLOOR
CUMBERLAND MD
21502-2569
US

IV. Provider business mailing address

13005 LEWIS HEIGHTS DR SW
LAVALE MD
21502-6512
US

V. Phone/Fax

Practice location:
  • Phone: 240-964-8416
  • Fax: 240-964-8601
Mailing address:
  • Phone: 240-727-8626
  • Fax: 877-284-3984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberN00111
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberN00111
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberN00111
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberN00111
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberN00111
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberN00111
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: