Provider Demographics
NPI:1730760265
Name:GRADL, BECKY A (MPH, RD, LDN, CHES)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:A
Last Name:GRADL
Suffix:
Gender:F
Credentials:MPH, RD, LDN, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 PARKVIEW CT
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-1467
Mailing Address - Country:US
Mailing Address - Phone:847-651-6351
Mailing Address - Fax:
Practice Address - Street 1:743 PARKVIEW CT
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-1467
Practice Address - Country:US
Practice Address - Phone:847-651-6351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006943133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered