Healthcare Provider Details

I. General information

NPI: 1417376443
Provider Name (Legal Business Name): KAREN PICINICH R.D. CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1285 MONTAUK HWY
COPIAGUE NY
11726-4936
US

IV. Provider business mailing address

66 W GATES AVE
LINDENHURST NY
11757-4739
US

V. Phone/Fax

Practice location:
  • Phone: 631-767-3410
  • Fax:
Mailing address:
  • Phone: 631-767-3410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number006198-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number006198-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number006198-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: