Healthcare Provider Details

I. General information

NPI: 1063058808
Provider Name (Legal Business Name): KATIE REBECCA CONRAD MCCOY RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 MIAMI VALLEY DR
DAYTON OH
45459
US

IV. Provider business mailing address

1705 BLEDSOE DR
BELLBROOK OH
45305-1314
US

V. Phone/Fax

Practice location:
  • Phone: 937-765-1363
  • Fax:
Mailing address:
  • Phone: 937-765-1363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number8169
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: