Provider Demographics
NPI:1306201801
Name:MOSS, OLIVIA (MS, RD)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W VAN BUREN ST
Mailing Address - Street 2:SUITE 425
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-5500
Mailing Address - Country:US
Mailing Address - Phone:312-942-8233
Mailing Address - Fax:
Practice Address - Street 1:1700 W VAN BUREN ST
Practice Address - Street 2:SUITE 425
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-5500
Practice Address - Country:US
Practice Address - Phone:312-942-8233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006558133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered