Healthcare Provider Details

I. General information

NPI: 1477818748
Provider Name (Legal Business Name): CYNTHIA A CARLSON RD,LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10432 LINDER AVE
OAK LAWN IL
60453-4639
US

IV. Provider business mailing address

3339 N BELL AVE UNIT 3
CHICAGO IL
60618
US

V. Phone/Fax

Practice location:
  • Phone: 773-425-2706
  • Fax: 773-296-1527
Mailing address:
  • Phone: 773-425-2706
  • Fax: 773-296-1527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number164000634
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number164000634
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number164000634
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164000634
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number164000634
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number164000634
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number164000634
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: