Healthcare Provider Details

I. General information

NPI: 1366781676
Provider Name (Legal Business Name): MARY L HALLIBURTON RDN,CSR, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2013
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4741 JOEL DRIVE APT 33
EL PASO TX
79924
US

IV. Provider business mailing address

4741 JOEL DR APT 33
EL PASO TX
79924-6968
US

V. Phone/Fax

Practice location:
  • Phone: 915-490-1718
  • Fax: 915-307-8678
Mailing address:
  • Phone: 915-490-1718
  • Fax: 915-307-8678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberDT81903
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberDT81903
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: