Provider Demographics
NPI:1306816798
Name:BARRA, DENISE (RD)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:BARRA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8051
Mailing Address - Fax:
Practice Address - Street 1:26 CITY HALL MALL
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4754
Practice Address - Country:US
Practice Address - Phone:617-629-6444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA549133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0015211OtherNEIGHBORHOOD HEALTH PLAN
MALD0030OtherBLUE CROSS
MA680078OtherTUFTS HEALTH PLAN
MAAA36166OtherHARVARD PILGRIM
MAMT0498Medicare ID - Type Unspecified