Provider Demographics
NPI:1871731943
Name:THEBERGE, CHRISTOPHER STEPHEN (RD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:STEPHEN
Last Name:THEBERGE
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1833
Mailing Address - Country:US
Mailing Address - Phone:617-442-7400
Mailing Address - Fax:
Practice Address - Street 1:435 WARREN ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1833
Practice Address - Country:US
Practice Address - Phone:617-442-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2626133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered