Provider Demographics
NPI:1821425224
Name:BRAY, MOLLY A (RD,LD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:A
Last Name:BRAY
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 1:1129 N WINCHESTER AVE
Mailing Address - Street 2:APT. 3F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3719
Mailing Address - Country:US
Mailing Address - Phone:651-206-4585
Mailing Address - Fax:
Practice Address - Street 1:1129 N WINCHESTER AVE
Practice Address - Street 2:APT. 3F
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3719
Practice Address - Country:US
Practice Address - Phone:651-206-4585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005958133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered