Healthcare Provider Details

I. General information

NPI: 1588145171
Provider Name (Legal Business Name): LEA PEYTON GEBHARDT PHD, RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 W 12TH ST STE E4
AUSTIN TX
78701-1703
US

IV. Provider business mailing address

4709 AVENUE G
AUSTIN TX
78751-3120
US

V. Phone/Fax

Practice location:
  • Phone: 512-765-5947
  • Fax:
Mailing address:
  • Phone: 512-788-6794
  • Fax: 512-519-8768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDT80880
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: