Provider Demographics
NPI:1851921100
Name:BOETTCHER, SUSAN (RD, LDN)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:
Last Name:BOETTCHER
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9409 MENARD AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9409 MENARD AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2337
Practice Address - Country:US
Practice Address - Phone:708-424-5909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
IL363341133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered