Healthcare Provider Details

I. General information

NPI: 1154465706
Provider Name (Legal Business Name): COLLEEN BEWLEY RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W RANDOL MILL RD
ARLINGTON TX
76012-2504
US

IV. Provider business mailing address

5512 MARSHFIELD CT
ARLINGTON TX
76016-2246
US

V. Phone/Fax

Practice location:
  • Phone: 817-548-6100
  • Fax:
Mailing address:
  • Phone: 817-496-6012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT05920
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: