MEDICARE: MS. SUSAN K PHILLIP NDTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number
1	133NN1002X	Nutrition Education Nutritionist
2	174H00000X	Health Educator
3	136A00000X	Registered Dietetic Technician	1018812

General Provider Information

NPI Number	:	1225592736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN K PHILLIP NDTR

Provider Business Mailing Address
First Line	:	67 GLENDALE ST
Second Line	:
City	:	DORCHESTER
State	:	MA
Zip	:	02125-2404
Country	:	US
Telephone Number	:	617-233-4950
Fax Number	:

Provider Business Practice Location Address
First Line	:	67 GLENDALE ST
Second Line	:
City	:	DORCHESTER
State	:	MA
Zip	:	02125-2404
Country	:	US
Telephone Number	:	617-233-4950
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2019
Last Update Date	:	03/18/2019

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