Provider Demographics
NPI:1679663991
Name:SUTH, ANDREW BLAKE (PHD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:BLAKE
Last Name:SUTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4451 N PAULINA ST
Mailing Address - Street 2:APT. 3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5348
Mailing Address - Country:US
Mailing Address - Phone:773-907-0364
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD
Practice Address - Street 2:SUITE 602
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3606
Practice Address - Country:US
Practice Address - Phone:773-718-0364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical