Provider Demographics
NPI:1144620261
Name:MOTA, JULIE ANN (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:MOTA
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 S MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2805
Mailing Address - Country:US
Mailing Address - Phone:708-945-0368
Mailing Address - Fax:
Practice Address - Street 1:728 S MADISON AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2805
Practice Address - Country:US
Practice Address - Phone:708-945-0368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.001268133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric