Healthcare Provider Details

I. General information

NPI: 1154995165
Provider Name (Legal Business Name): COURTNEY ELIZABETH DEPA RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 05/14/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

8219 N ODELL AVE
NILES IL
60714-2509
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164008318
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: