Provider Demographics
NPI:1346436508
Name:BALTASI, CAREN (LDN,CCN)
Entity Type:Individual
Prefix:MS
First Name:CAREN
Middle Name:
Last Name:BALTASI
Suffix:
Gender:F
Credentials:LDN,CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 WAUKEGAN RD
Mailing Address - Street 2:SUITE 255
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5514
Mailing Address - Country:US
Mailing Address - Phone:847-405-7611
Mailing Address - Fax:
Practice Address - Street 1:2525 WAUKEGAN RD
Practice Address - Street 2:SUITE 255
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-5514
Practice Address - Country:US
Practice Address - Phone:847-405-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004395133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist