Healthcare Provider Details

I. General information

NPI: 1902197155
Provider Name (Legal Business Name): MONICA HAYDEE GONZALEZ RD,LDN,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 E BELVIDERE RD STE 185
GRAYSLAKE IL
60030-2026
US

IV. Provider business mailing address

1475 E BELVIDERE RD STE 185
GRAYSLAKE IL
60030-2026
US

V. Phone/Fax

Practice location:
  • Phone: 847-534-3278
  • Fax: 847-535-7260
Mailing address:
  • Phone: 847-534-3278
  • Fax: 847-535-7260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.005449
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: