Provider Demographics
NPI:1700414505
Name:BLYTH, ALEXANDER A
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:A
Last Name:BLYTH
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 1:1104 ISABEL DR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-3510
Mailing Address - Country:US
Mailing Address - Phone:815-355-6026
Mailing Address - Fax:
Practice Address - Street 1:1104 ISABEL DR
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-3510
Practice Address - Country:US
Practice Address - Phone:815-355-6026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-29
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-24-78078103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst