Basic Information
| Provider Information | |||||||||
| NPI: | 1568682284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICETICH | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9015 WITHAM LN | ||||||||
| Address2: | |||||||||
| City: | WOODRIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605177621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082295429 | ||||||||
| FaxNumber: | 7082295308 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 W 95TH ST | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608052701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082295429 | ||||||||
| FaxNumber: | 7082295308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.