Healthcare Provider Details

I. General information

NPI: 1649993916
Provider Name (Legal Business Name): MARCELLA A DOUCET MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 10/29/2023
Certification Date: 10/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11630 S KEDZIE AVE
MERRIONETTE PARK IL
60803-6302
US

IV. Provider business mailing address

11630 S KEDZIE AVE
MERRIONETTE PARK IL
60803-6302
US

V. Phone/Fax

Practice location:
  • Phone: 708-438-8032
  • Fax: 708-389-9088
Mailing address:
  • Phone: 708-438-8032
  • Fax: 708-389-9088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number37003501A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number164.008601
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: