Provider Demographics
NPI:1881461945
Name:ROBERGE, MOLLY (MS, RDN)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:ROBERGE
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W WASHINGTON AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-2868
Mailing Address - Country:US
Mailing Address - Phone:652-955-3706
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-263-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5404-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered