Provider Demographics
NPI:1013354836
Name:BRANDT, LISA ANN (RD, LDN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:BRANDT
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 1:2700 DEKALB AVE
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3127
Mailing Address - Country:US
Mailing Address - Phone:815-756-6174
Mailing Address - Fax:815-748-3784
Practice Address - Street 1:2700 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3127
Practice Address - Country:US
Practice Address - Phone:815-756-6174
Practice Address - Fax:815-748-3784
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004217133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered