Healthcare Provider Details

I. General information

NPI: 1538112321
Provider Name (Legal Business Name): HELEN BOUZALAS RD, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 POLY PL
BROOKLYN NY
11209-7104
US

IV. Provider business mailing address

967 81ST ST
BROOKLYN NY
11228-2800
US

V. Phone/Fax

Practice location:
  • Phone: 718-836-6600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number839022
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: