Provider Demographics
NPI:1730185885
Name:COOPERSMITH, SUSAN LYNNE (RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LYNNE
Last Name:COOPERSMITH
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 W TOUHY AVE
Mailing Address - Street 2:UNIT C
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-2956
Mailing Address - Country:US
Mailing Address - Phone:773-262-5848
Mailing Address - Fax:
Practice Address - Street 1:7301 N LINCOLN AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-1709
Practice Address - Country:US
Practice Address - Phone:847-675-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205817Medicare ID - Type Unspecified