Provider Demographics
NPI:1649797457
Name:LEIVA, CAITLYN ELIZABETH (MS, RD)
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:ELIZABETH
Last Name:LEIVA
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E SUPERIOR ST STE 520
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2914
Mailing Address - Country:US
Mailing Address - Phone:312-472-5823
Mailing Address - Fax:
Practice Address - Street 1:250 E SUPERIOR ST STE 520
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2914
Practice Address - Country:US
Practice Address - Phone:312-472-5823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006971133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered