Healthcare Provider Details

I. General information

NPI: 1144620261
Provider Name (Legal Business Name): JULIE ANN MOTA MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 S MADISON AVE
LA GRANGE IL
60525-2805
US

IV. Provider business mailing address

728 S MADISON AVE
LA GRANGE IL
60525-2805
US

V. Phone/Fax

Practice location:
  • Phone: 708-945-0368
  • Fax:
Mailing address:
  • Phone: 708-945-0368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number164.001268
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: