Provider Demographics
NPI:1174621064
Name:SIDEWATER, DEBRA R (RD,MSW)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:R
Last Name:SIDEWATER
Suffix:
Gender:F
Credentials:RD,MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 VANDERVERE RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2745
Mailing Address - Country:US
Mailing Address - Phone:860-232-0780
Mailing Address - Fax:
Practice Address - Street 1:555 WILLARD AVE
Practice Address - Street 2:NUTRITION CLINIC, SECOND FLOOR
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2631
Practice Address - Country:US
Practice Address - Phone:860-667-6797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CT000128133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
R464768OtherREGISTERED DIETITIAN
1027OtherCERTIFIED DIABETES EDUCAT
CT000128OtherCERTIFIED DIETITIAN