Provider Demographics
NPI:1386806107
Name:DEBORD, BRENDA SUE (MA,RD,LD,CD)
Entity type:Individual
Prefix:MISS
First Name:BRENDA
Middle Name:SUE
Last Name:DEBORD
Suffix:
Gender:F
Credentials:MA,RD,LD,CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7216 HILL PARK WAY
Mailing Address - Street 2:APT. 256
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-7155
Mailing Address - Country:US
Mailing Address - Phone:502-458-3510
Mailing Address - Fax:
Practice Address - Street 1:800 ZORN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1433
Practice Address - Country:US
Practice Address - Phone:502-287-4513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0595133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY-0595OtherLICENSED DIETITIAN
IN37000155AOtherCERTIFIED DIETITIAN