Provider Demographics
NPI:1396295572
Name:SOUTHGATE, KARL (PSYD, LPC)
Entity type:Individual
Prefix:DR
First Name:KARL
Middle Name:
Last Name:SOUTHGATE
Suffix:
Gender:M
Credentials:PSYD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5544 N WINTHROP AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1410
Mailing Address - Country:US
Mailing Address - Phone:312-965-7379
Mailing Address - Fax:
Practice Address - Street 1:8 S MICHIGAN AVE
Practice Address - Street 2:SUITE 2100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-3357
Practice Address - Country:US
Practice Address - Phone:312-344-1081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012318101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health