Provider Demographics
NPI:1427162056
Name:HARRIS, MICHEL D (RD, LDN, CDE)
Entity type:Individual
Prefix:MRS
First Name:MICHEL
Middle Name:D
Last Name:HARRIS
Suffix:
Gender:F
Credentials:RD, LDN, CDE
Other - Prefix:MISS
Other - First Name:MICHEL
Other - Middle Name:D
Other - Last Name:DI VITO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:4356 N KENMORE AVE
Mailing Address - Street 2:APT 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1330
Mailing Address - Country:US
Mailing Address - Phone:312-550-3612
Mailing Address - Fax:
Practice Address - Street 1:3523 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-1137
Practice Address - Country:US
Practice Address - Phone:773-929-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164003376133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164.003376OtherLICENSED DIETITIAN NUTRITIONIST
IL20120370OtherCERTIFIED DIABETES EDUCATOR
IL46-5085580OtherTAX ID