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General NPI Number Information
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NPI Number | 1861700544
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Entity Type | Organization
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Legal Business Name | CHICAGO PRACTICE IN PSYCHOLOGY
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Dates
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Enumeration Date | 09/16/2010
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Last Update Date | 09/16/2010
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Provider Practice Location Address
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Address Line | 53 WEST JACKSON SUITE 602
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City | CHICAGO
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State | IL
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Zip | 60604-3448
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Country | US
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Telephone | 773-718-0364
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Fax | 312-212-1705
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Provider Business Mailing Address
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Address Line | 53 WEST JACKSON SUITE 602
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City | CHICAGO
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State | IL
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Zip | 60604-3448
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Country | US
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Telephone | 773-718-0364
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Fax | 312-212-1705
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ANDREW BLAKE SUTH
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Credential | PH.D.
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Telephone | 773-718-0364
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071006431
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License Number State | IL
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