Provider Demographics
NPI:1740807437
Name:SCHRADER, LISA (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SCHRADER
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 CHICAGO AVE UNIT 505
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2381
Mailing Address - Country:US
Mailing Address - Phone:630-779-0120
Mailing Address - Fax:
Practice Address - Street 1:733 CHICAGO AVE UNIT 505
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2381
Practice Address - Country:US
Practice Address - Phone:630-779-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2023-08-09
Deactivation Date:2021-09-14
Deactivation Code:
Reactivation Date:2023-08-09
Provider Licenses
StateLicense IDTaxonomies
IL164.007414133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered