Provider Demographics
NPI:1831832583
Name:GOUDARZI, LESLIE (MS, RD, LD, CNSC)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GOUDARZI
Suffix:
Gender:F
Credentials:MS, RD, LD, CNSC
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:GOUDARZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LD, CNSC
Mailing Address - Street 1:1111 E CESAR CHAVEZ ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-4209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5800 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-4204
Practice Address - Country:US
Practice Address - Phone:512-978-8470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT04733133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered