Provider Demographics
NPI:1477818748
Name:CARLSON, CYNTHIA A (RD,LDN)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:CARLSON
Suffix:
Gender:F
Credentials:RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3339 N BELL AVE
Mailing Address - Street 2:UNIT 3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618
Mailing Address - Country:US
Mailing Address - Phone:773-425-2706
Mailing Address - Fax:773-296-1527
Practice Address - Street 1:10432 LINDER AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4639
Practice Address - Country:US
Practice Address - Phone:773-425-2706
Practice Address - Fax:773-296-1527
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164000634132700000X, 133N00000X, 133NN1002X, 133V00000X, 133VN1004X, 133VN1005X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No132700000XDietary & Nutritional Service ProvidersDietary Manager
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210698Medicare PIN