Provider Demographics
NPI:1265676126
Name:STEIN, SUSAN A (RD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:A
Last Name:STEIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8848 LOWELL TER
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1840
Mailing Address - Country:US
Mailing Address - Phone:847-502-1359
Mailing Address - Fax:847-679-8848
Practice Address - Street 1:4240 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-2070
Practice Address - Country:US
Practice Address - Phone:847-502-1359
Practice Address - Fax:847-679-8848
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005023133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered