Provider Demographics
NPI:1063272870
Name:PODOLAK, KACEY (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:KACEY
Middle Name:
Last Name:PODOLAK
Suffix:
Gender:
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 CHERRY ST STE 1900
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-2673
Mailing Address - Country:US
Mailing Address - Phone:419-251-3878
Mailing Address - Fax:
Practice Address - Street 1:2222 CHERRY ST STE 1000
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2673
Practice Address - Country:US
Practice Address - Phone:419-251-8042
Practice Address - Fax:419-251-7714
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.7824133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0046151Medicaid