Provider Demographics
NPI:1669293890
Name:BLYTHE, JUSTIN DAVID JR
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:DAVID
Last Name:BLYTHE
Suffix:JR
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 1:299 N DUNTON AVE APT 418
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-5941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3204
Practice Address - Country:US
Practice Address - Phone:847-990-5666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041548967163WN0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0800XNursing Service ProvidersRegistered NurseNeuroscience