Healthcare Provider Details

I. General information

NPI: 1760980825
Provider Name (Legal Business Name): STACEY BARTA RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5895 SAN FELIPE ST
HOUSTON TX
77057-3061
US

IV. Provider business mailing address

3810 LAW ST APT 216
HOUSTON TX
77005-1283
US

V. Phone/Fax

Practice location:
  • Phone: 855-481-1149
  • Fax:
Mailing address:
  • Phone: 512-731-3772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86086306
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: