Provider Demographics
NPI:1003988130
Name:LARSEN, LILLIE (REGISTERED DIETICIAN)
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:REGISTERED DIETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13707 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3141
Mailing Address - Country:US
Mailing Address - Phone:815-206-1067
Mailing Address - Fax:815-338-6297
Practice Address - Street 1:285 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6260
Practice Address - Country:US
Practice Address - Phone:815-356-2383
Practice Address - Fax:815-356-2385
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered