1851923189 NPI number — MS. TRACY NICOLE GOTTSCHALK REGISTERED DIETITIAN

Table of content: MS. TRACY NICOLE GOTTSCHALK REGISTERED DIETITIAN (NPI 1851923189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851923189 NPI number — MS. TRACY NICOLE GOTTSCHALK REGISTERED DIETITIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOTTSCHALK
Provider First Name:
TRACY
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
REGISTERED DIETITIAN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851923189
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
49 BEVERLY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTCLAIR
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07043-2401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-230-7648
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 ORANGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTCLAIR
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07042-4451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-230-7648
Provider Business Practice Location Address Fax Number:
888-649-4924
Provider Enumeration Date:
02/05/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 86058451 . This is a "COMMISSION ON DIETETIC REGISTRATION" identifier . This identifiers is of the category "OTHER".




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