Basic Information
| Provider Information | |||||||||
| NPI: | 1164453403 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RHODES | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | L.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1420 VICEROY DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752352208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143582300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1250 8TH AVE STE 135 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179238050 | ||||||||
| FaxNumber: | 8179200562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | LD 5675 | OH | N | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 133V00000X | DT84978 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | RHMT73321 | 01 | OH | PIN NUMBER | OTHER | DT84978 | 01 | TN | COMMISSION ON DIETETIC REGISTRATION | OTHER |