Provider Demographics
NPI:1043708795
Name:EBERHARD, ALEXA (CCN, LDN)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:EBERHARD
Suffix:
Gender:F
Credentials:CCN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17023 HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2739
Mailing Address - Country:US
Mailing Address - Phone:708-614-1222
Mailing Address - Fax:
Practice Address - Street 1:17023 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2739
Practice Address - Country:US
Practice Address - Phone:708-614-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.006837133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist