Provider Demographics
NPI:1588954622
Name:MOUTAFIS, THERESA M (RD, LDN, CDE, IBCLC)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:MOUTAFIS
Suffix:
Gender:F
Credentials:RD, LDN, CDE, IBCLC
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:CAMARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:62 APPLETON ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-1630
Mailing Address - Country:US
Mailing Address - Phone:315-730-1858
Mailing Address - Fax:
Practice Address - Street 1:62 APPLETON ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-1630
Practice Address - Country:US
Practice Address - Phone:315-730-1858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1009944133V00000X
NY133V00000X
MA000003134133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered