MEDICARE: BALANCE DIETETICS-NUTRITION & PSYCHOLOGICAL EATING DISORDER PLLC

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	133V00000X	Registered Dietitian
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1982148052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCE DIETETICS-NUTRITION & PSYCHOLOGICAL EATING DISORDER PLLC

Provider Business Mailing Address
First Line	:	112 W 27TH ST FL 7
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10001-6240
Country	:	US
Telephone Number	:	212-645-6903
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 W 27TH ST FL 7
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10001-6240
Country	:	US
Telephone Number	:	212-645-6903
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER AND EXECUTIVE DIRECTOR
Name	:	MS. MELAINIE ROGERS
Credential	:	MS, RDN, CEDRD
Telephone Number	:	212-645-6903

Provider Enumeration Date	:	12/08/2016
Last Update Date	:	12/08/2016

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