Provider Demographics
NPI:1588385132
Name:ROUNDTREE, BRENDA LEE (NDTR)
Entity type:Individual
Prefix:PROF
First Name:BRENDA
Middle Name:LEE
Last Name:ROUNDTREE
Suffix:
Gender:F
Credentials:NDTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 E COUNTRY SHADOWS ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-9026
Mailing Address - Country:US
Mailing Address - Phone:602-853-6927
Mailing Address - Fax:
Practice Address - Street 1:3103 E COUNTRY SHADOWS ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298-9026
Practice Address - Country:US
Practice Address - Phone:602-853-6927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1085276133N00000X, 133NN1002X, 136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education