Provider Demographics
NPI:1073254199
Name:SQUIER, MADELINE (MS RDN LDN CLC)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:SQUIER
Suffix:
Gender:F
Credentials:MS RDN LDN CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 SKYRIDGE DR UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-1047
Mailing Address - Country:US
Mailing Address - Phone:414-861-1875
Mailing Address - Fax:
Practice Address - Street 1:2515 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2730
Practice Address - Country:US
Practice Address - Phone:414-861-1875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164008001133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered