Provider Demographics
NPI:1366781676
Name:HALLIBURTON, MARY L (RDN,CSR, LD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:HALLIBURTON
Suffix:
Gender:F
Credentials:RDN,CSR, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4741 JOEL DR APT 33
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-6968
Mailing Address - Country:US
Mailing Address - Phone:915-490-1718
Mailing Address - Fax:915-307-8678
Practice Address - Street 1:4741 JOEL DRIVE
Practice Address - Street 2:APT 33
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924
Practice Address - Country:US
Practice Address - Phone:915-490-1718
Practice Address - Fax:915-307-8678
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81903133VN1005X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic