Provider Demographics
NPI:1447520770
Name:STAHL, THERESA (RD, LDN)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:STAHL
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13005 LEWIS HEIGHTS DR SW
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6512
Mailing Address - Country:US
Mailing Address - Phone:240-727-8626
Mailing Address - Fax:877-284-3984
Practice Address - Street 1:12501 WILLOWBROOK RD
Practice Address - Street 2:WOC 2ND FLOOR
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2569
Practice Address - Country:US
Practice Address - Phone:240-964-8416
Practice Address - Fax:240-964-8601
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDN00111133NN1002X, 133V00000X, 133VN1004X, 133VN1005X, 133VN1006X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD244752ZB9FMedicare PIN