Provider Demographics
NPI:1801960125
Name:DEMUTH, PETER WALTER (PSYD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:WALTER
Last Name:DEMUTH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 SHERIDAN ROAD
Mailing Address - Street 2:#2
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202
Mailing Address - Country:US
Mailing Address - Phone:847-424-9304
Mailing Address - Fax:
Practice Address - Street 1:717 MAIN ST
Practice Address - Street 2:2ND FLOOR EAST
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202
Practice Address - Country:US
Practice Address - Phone:847-424-9304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
01622016OtherBCBS PRO #
IL413780Medicare ID - Type Unspecified