Provider Demographics
NPI:1093599045
Name:LIBBY, CYNTHIA (MS, RD, LDN, CEDS)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:LIBBY
Suffix:
Gender:F
Credentials:MS, RD, LDN, CEDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15705 OLD ORCHARD CT UNIT 2S
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-3569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 PINE ST SE STE 150
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4877
Practice Address - Country:US
Practice Address - Phone:703-259-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007138133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered