Provider Demographics
NPI:1609581453
Name:EYTALIS, ANDREW BENJAMIN
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:BENJAMIN
Last Name:EYTALIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 N PERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6225
Mailing Address - Country:US
Mailing Address - Phone:815-975-3330
Mailing Address - Fax:
Practice Address - Street 1:695 N PERRYVILLE RD STE 4
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6225
Practice Address - Country:US
Practice Address - Phone:779-368-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-17
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL178021163101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program