Provider Demographics
NPI:1578039996
Name:HAEBIG, ALYSON
Entity Type:Individual
Prefix:
First Name:ALYSON
Middle Name:
Last Name:HAEBIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4631 N PAULINA ST APT 303
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-4546
Mailing Address - Country:US
Mailing Address - Phone:920-539-3454
Mailing Address - Fax:
Practice Address - Street 1:5 REVERE DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1567
Practice Address - Country:US
Practice Address - Phone:800-736-3739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL86084099133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty