Provider Demographics
NPI:1992917686
Name:PICASSO-EDWARDS, THERESE (RD)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:PICASSO-EDWARDS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SNOWY LN.
Mailing Address - Street 2:
Mailing Address - City:RED LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59068-9645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 W 21ST ST
Practice Address - Street 2:
Practice Address - City:RED LODGE
Practice Address - State:MT
Practice Address - Zip Code:59068
Practice Address - Country:US
Practice Address - Phone:406-446-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT495133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered