Provider Demographics
NPI:1811993074
Name:GUSTAFSON, CARLY D (MS RD LDN)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:D
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MS RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 W BERWYN AVE
Mailing Address - Street 2:APT 2N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1141
Mailing Address - Country:US
Mailing Address - Phone:630-254-1477
Mailing Address - Fax:773-843-2748
Practice Address - Street 1:4100 W 42ND STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632
Practice Address - Country:US
Practice Address - Phone:773-843-6709
Practice Address - Fax:773-843-2748
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered