Healthcare Provider Details

I. General information

NPI: 1497767669
Provider Name (Legal Business Name): SCOTT DAVID PYTLUK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MICHIGAN AVE SUITE #1510
CHICAGO IL
60602-3402
US

IV. Provider business mailing address

30 N MICHIGAN AVE STE 1022
CHICAGO IL
60602-3758
US

V. Phone/Fax

Practice location:
  • Phone: 312-364-9965
  • Fax:
Mailing address:
  • Phone: 312-364-9965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071005952
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number071005952
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071005952
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: