Provider Demographics
NPI:1366198012
Name:RISLEY, THERESA (RD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:RISLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:RISLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:222 SCHANCK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2974
Mailing Address - Country:US
Mailing Address - Phone:800-920-9928
Mailing Address - Fax:800-615-9936
Practice Address - Street 1:222 SCHANCK RD STE 200
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2974
Practice Address - Country:US
Practice Address - Phone:800-920-9928
Practice Address - Fax:800-615-9936
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ960795133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered