Provider Demographics
NPI:1750115358
Name:SECONTINE, STEPHANIE GRACE (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GRACE
Last Name:SECONTINE
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E ADAMS ST APT 611
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-5644
Mailing Address - Country:US
Mailing Address - Phone:248-505-1976
Mailing Address - Fax:
Practice Address - Street 1:30 E ADAMS ST APT 611
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-5644
Practice Address - Country:US
Practice Address - Phone:248-505-1976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-27
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.008397133V00000X
TXDT90501133V00000X
TN4968133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered