Provider Demographics
NPI:1306050471
Name:SEWERYN, LAURA MARIE (RD)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MARIE
Last Name:SEWERYN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10943 MAJOR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2410
Mailing Address - Country:US
Mailing Address - Phone:708-422-6200
Mailing Address - Fax:
Practice Address - Street 1:10400 SOUTHWEST HWY
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1367
Practice Address - Country:US
Practice Address - Phone:708-581-7308
Practice Address - Fax:708-581-7309
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164001840133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1467471540OtherGROUP NPI
211475Medicare PIN
1467471540OtherGROUP NPI