Provider Demographics
NPI:1073629911
Name:MATTHEWS, LISA G (RD, LDN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:G
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 ACORN LN
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2157
Mailing Address - Country:US
Mailing Address - Phone:847-816-4687
Mailing Address - Fax:
Practice Address - Street 1:200 W GOLF RD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3234
Practice Address - Country:US
Practice Address - Phone:847-990-5770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
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