Healthcare Provider Details

I. General information

NPI: 1679663991
Provider Name (Legal Business Name): ANDREW BLAKE SUTH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2006
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 S BRIDGE ST
YORKVILLE IL
60560-1591
US

IV. Provider business mailing address

11575 RANCHO FIESTA RD
CARMEL VALLEY CA
93924-9458
US

V. Phone/Fax

Practice location:
  • Phone: 773-718-0364
  • Fax:
Mailing address:
  • Phone: 773-718-0354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY33640
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071006431
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: