Provider Demographics
NPI:1588285704
Name:LEVINE, MELISSA JOY (RD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JOY
Last Name:LEVINE
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 1:2121 ILLINOIS RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5234
Mailing Address - Country:US
Mailing Address - Phone:847-682-5063
Mailing Address - Fax:
Practice Address - Street 1:901 BUCCANEER DR
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-7044
Practice Address - Country:US
Practice Address - Phone:847-682-5063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004133133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty