Provider Demographics
NPI:1336294024
Name:MOULTHROP, MARK A (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:MOULTHROP
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 1:636 CHURCH ST
Mailing Address - Street 2:SUITE 407
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4508
Mailing Address - Country:US
Mailing Address - Phone:847-869-3702
Mailing Address - Fax:847-869-8945
Practice Address - Street 1:636 CHURCH ST
Practice Address - Street 2:SUITE 407
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4508
Practice Address - Country:US
Practice Address - Phone:847-869-3702
Practice Address - Fax:847-869-8945
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL768240Medicare ID - Type Unspecified