Provider Demographics
NPI:1831419373
Name:BALSOME, LUCINDA MARIA (MS,RD)
Entity type:Individual
Prefix:
First Name:LUCINDA
Middle Name:MARIA
Last Name:BALSOME
Suffix:
Gender:F
Credentials:MS,RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 KELSEY LN
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-5015
Mailing Address - Country:US
Mailing Address - Phone:860-796-4160
Mailing Address - Fax:
Practice Address - Street 1:62 KELSEY LN
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-5015
Practice Address - Country:US
Practice Address - Phone:860-796-4160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000080133NN1002X
IL720769133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education