Healthcare Provider Details

I. General information

NPI: 1487995486
Provider Name (Legal Business Name): LISA MIRE RD, CSP, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2013
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CHILDRENS DR
COLUMBUS OH
43205-2639
US

IV. Provider business mailing address

700 CHILDRENS DR
COLUMBUS OH
43205-2639
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-6415
  • Fax:
Mailing address:
  • Phone: 614-722-6415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberLD.08393
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberL002586
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: