Provider Demographics
NPI:1386882793
Name:BALTHAZOR, MICHAEL J (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:BALTHAZOR
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 1:4711 GOLF RD
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1224
Mailing Address - Country:US
Mailing Address - Phone:847-933-9339
Mailing Address - Fax:847-933-0874
Practice Address - Street 1:4711 GOLF RD
Practice Address - Street 2:SUITE 1100
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1224
Practice Address - Country:US
Practice Address - Phone:847-933-9339
Practice Address - Fax:847-933-0874
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006684103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical