Provider Demographics
NPI:1992070015
Name:BRERETON, THERESA (MS,RD,CDN,CDE)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BRERETON
Suffix:
Gender:F
Credentials:MS,RD,CDN,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 E 52ND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2404
Mailing Address - Country:US
Mailing Address - Phone:718-773-7237
Mailing Address - Fax:
Practice Address - Street 1:6110 QUEENS BLVD
Practice Address - Street 2:ESPRIT MEDICAL CARE
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-5776
Practice Address - Country:US
Practice Address - Phone:718-397-2002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY720882133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered