Provider Demographics
NPI:1871869016
Name:BOULDIN, THERESA SUZANNE (RD, CSG)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:SUZANNE
Last Name:BOULDIN
Suffix:
Gender:F
Credentials:RD, CSG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 S 6TH AVE
Mailing Address - Street 2:MAIL CODE 0-002A1
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85723-0001
Mailing Address - Country:US
Mailing Address - Phone:520-792-1450
Mailing Address - Fax:520-518-5620
Practice Address - Street 1:3601 S 6TH AVE
Practice Address - Street 2:MAIL CODE 0-002A1
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723-0001
Practice Address - Country:US
Practice Address - Phone:520-792-1450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALD003331OtherGA DIETITIAN LICENSE