Provider Demographics
NPI:1497430979
Name:KOSTOS, LEAH ROSE (RD)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:ROSE
Last Name:KOSTOS
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 1:826 W TOUHY AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3352
Mailing Address - Country:US
Mailing Address - Phone:847-825-0770
Mailing Address - Fax:312-648-0155
Practice Address - Street 1:826 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3352
Practice Address - Country:US
Practice Address - Phone:847-825-0770
Practice Address - Fax:312-648-0155
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164009226133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered