Provider Demographics
NPI:1477500825
Name:MOUTON, ANDREW B (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:B
Last Name:MOUTON
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 1:10640 W 165TH STREET
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5653
Mailing Address - Country:US
Mailing Address - Phone:708-364-0261
Mailing Address - Fax:708-364-6019
Practice Address - Street 1:10640 W 165TH STREET
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5653
Practice Address - Country:US
Practice Address - Phone:708-364-0261
Practice Address - Fax:708-364-6019
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004325103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071004325OtherSTATE LICENSE
IL215684Medicare PIN
IL211335Medicare PIN
IL206975Medicare PIN
IL208306Medicare PIN
IL215683Medicare PIN