=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992070015
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA BRERETON MS,RD,CDN,CDE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2012
-----------------------------------------------------
Last Update Date | 03/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6110 QUEENS BLVD ESPRIT MEDICAL CARE
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-5776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-397-2002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 E 52ND ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11203-2404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-773-7237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 720882
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------