Provider Demographics
NPI:1285871426
Name:FREEMAN, BETH STACY (RD CDN)
Entity type:Individual
Prefix:MRS
First Name:BETH
Middle Name:STACY
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:RD CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 W 256TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-2413
Mailing Address - Country:US
Mailing Address - Phone:917-796-2502
Mailing Address - Fax:
Practice Address - Street 1:455 W 256TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-2413
Practice Address - Country:US
Practice Address - Phone:917-796-2502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005987-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11898975OtherCAQH