Healthcare Provider Details

I. General information

NPI: 1417861394
Provider Name (Legal Business Name): MARY HALLORAN NDTR, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

857 CEDAR CREST DR
ELYRIA OH
44035-8985
US

IV. Provider business mailing address

857 CEDAR CREST DR
ELYRIA OH
44035-8985
US

V. Phone/Fax

Practice location:
  • Phone: 614-985-6567
  • Fax: 614-808-3854
Mailing address:
  • Phone: 614-985-6567
  • Fax: 614-808-3854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number2570
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: