Provider Demographics
NPI:1326123431
Name:GREENE, LISA (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
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 1:96 BRIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5539
Mailing Address - Country:US
Mailing Address - Phone:972-896-5858
Mailing Address - Fax:
Practice Address - Street 1:96 BRIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5539
Practice Address - Country:US
Practice Address - Phone:972-896-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05641133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX05641OtherTEXAS LICENSED DIETITIAN
TX05641OtherTEXAS LICENSED DIETITIAN