Provider Demographics
NPI:1487145017
Name:MAES, CECILY (MA, RDN, CD)
Entity type:Individual
Prefix:
First Name:CECILY
Middle Name:
Last Name:MAES
Suffix:
Gender:F
Credentials:MA, RDN, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 RUNAWAY BAY CIR APT 3C
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-8059
Mailing Address - Country:US
Mailing Address - Phone:574-309-1256
Mailing Address - Fax:
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1087
Practice Address - Country:US
Practice Address - Phone:574-647-6353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86014159133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered