Provider Demographics
NPI:1649090184
Name:SCHUBERT, SUZANNE
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:SCHUBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 HIDDEN LAKE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-3743
Mailing Address - Country:US
Mailing Address - Phone:812-639-9965
Mailing Address - Fax:
Practice Address - Street 1:721 E COURT ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944-2460
Practice Address - Country:US
Practice Address - Phone:217-466-4252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005564133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered