Provider Demographics
NPI:1699823880
Name:MCCLOSKEY, SUSAN (RD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MCCLOSKEY
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 1:1617 DEVEREUX RD
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-3750
Mailing Address - Country:US
Mailing Address - Phone:630-674-3223
Mailing Address - Fax:630-541-5870
Practice Address - Street 1:120 N OAK ST
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3829
Practice Address - Country:US
Practice Address - Phone:630-856-3750
Practice Address - Fax:630-856-7239
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.001582133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211227Medicare ID - Type Unspecified