Provider Demographics
NPI:1386803377
Name:WEST BLASKOVICH, COURTNEY M (PHD)
Entity type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:M
Last Name:WEST BLASKOVICH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N MCCLURG CT
Mailing Address - Street 2:#3803A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3044
Mailing Address - Country:US
Mailing Address - Phone:312-246-9166
Mailing Address - Fax:
Practice Address - Street 1:600 N MCCLURG CT
Practice Address - Street 2:#3803A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3044
Practice Address - Country:US
Practice Address - Phone:312-246-9166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007265103G00000X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent