Provider Demographics
NPI:1275966319
Name:ESTABROOK, ANNA (MM, MT-BC)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:ESTABROOK
Suffix:
Gender:F
Credentials:MM, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W BARKER AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1707
Mailing Address - Country:US
Mailing Address - Phone:309-256-3989
Mailing Address - Fax:
Practice Address - Street 1:1301 W BARKER AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1707
Practice Address - Country:US
Practice Address - Phone:309-256-3989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL11064225A00000X
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist