Healthcare Provider Details

I. General information

NPI: 1942254701
Provider Name (Legal Business Name): GINA M. REISS RD, LDN
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

714 N BETHLEHEM PIKE SUITE 300
LOWER GWYNEDD PA
19002-2655
US

IV. Provider business mailing address

6609 ERDRICK ST
PHILADELPHIA PA
19135-2601
US

V. Phone/Fax

Practice location:
  • Phone: 215-283-2833
  • Fax: 215-283-1919
Mailing address:
  • Phone: 215-333-1781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN001257
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: