Healthcare Provider Details

I. General information

NPI: 1194333971
Provider Name (Legal Business Name): LISA LOVEJOY RD, CSSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2020
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 S UNION AVE STE 300
TACOMA WA
98405-1387
US

IV. Provider business mailing address

3424 N 28TH ST
TACOMA WA
98407-6247
US

V. Phone/Fax

Practice location:
  • Phone: 253-459-6966
  • Fax:
Mailing address:
  • Phone: 253-302-0960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number723108
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number723108
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: