Provider Demographics
NPI:1568682284
Name:MICETICH, LISA MARIE (RD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MICETICH
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 1:9015 WITHAM LN
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-7621
Mailing Address - Country:US
Mailing Address - Phone:708-229-5429
Mailing Address - Fax:708-229-5308
Practice Address - Street 1:2800 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2701
Practice Address - Country:US
Practice Address - Phone:708-229-5429
Practice Address - Fax:708-229-5308
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1102317337043Medicare ID - Type Unspecified