Provider Demographics
NPI:1992096655
Name:GONTER-DRAY, REBECCA MARIE (RD CSP LD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:GONTER-DRAY
Suffix:
Gender:F
Credentials:RD CSP LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 N DORSET RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2453
Mailing Address - Country:US
Mailing Address - Phone:937-440-6530
Mailing Address - Fax:
Practice Address - Street 1:475 N DORSET RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2453
Practice Address - Country:US
Practice Address - Phone:937-440-6530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4144133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered