Provider Demographics
NPI:1528301959
Name:OLIVARES, STEPHANIE ALYCE (DTR , MS)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ALYCE
Last Name:OLIVARES
Suffix:
Gender:F
Credentials:DTR , MS
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ALYCE
Other - Last Name:BEHRENDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DTR, MS
Mailing Address - Street 1:14330 MIDWAY RD
Mailing Address - Street 2:STE 121
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-3522
Mailing Address - Country:US
Mailing Address - Phone:972-930-0260
Mailing Address - Fax:
Practice Address - Street 1:14330 MIDWAY RD
Practice Address - Street 2:STE 121
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-3522
Practice Address - Country:US
Practice Address - Phone:972-930-0260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist