MEDICARE: KIRSTEN ROBERTSON RDN, LD

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1201X	Obesity and Weight Management Nutrition Registered Dietitian	DT85784	TX
2	133V00000X	Registered Dietitian	DT85784	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DT85784	OTHER	TX	TEXAS DEPARTMENT OF LICENSING AND REGULATION

General Provider Information

NPI Number	:	1366072068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRSTEN ROBERTSON RDN, LD

Provider Business Mailing Address
First Line	:	PO BOX 844658
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-4658
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4500 SPRING AVE STE 130
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75210-1350
Country	:	US
Telephone Number	:	214-865-3060
Fax Number	:	214-865-3070

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

Provider Enumeration Date	:	01/22/2020
Last Update Date	:	01/12/2022

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