Provider Demographics
NPI:1720401391
Name:WITZ, SUSAN R (RD, LD)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:R
Last Name:WITZ
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 N SANDBURG TER
Mailing Address - Street 2:#301A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-8514
Mailing Address - Country:US
Mailing Address - Phone:312-944-0855
Mailing Address - Fax:312-944-0855
Practice Address - Street 1:1460 N SANDBURG TER
Practice Address - Street 2:#301A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-8514
Practice Address - Country:US
Practice Address - Phone:312-944-0855
Practice Address - Fax:312-944-0855
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-01
Last Update Date:2014-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.000255133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164.000256OtherSTATE OF ILLINOIS , DIVISION OF PROFESSIONAL REGULATION, LICENSE
IL636084OtherREGISTERED DIETITIAN, ACADEMY OF NUTRITION AND DIETETICS