Provider Demographics
NPI:1326661992
Name:OBANNONN, ANNA L (RBT)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:L
Last Name:OBANNONN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 EAGLE CTR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1945
Mailing Address - Country:US
Mailing Address - Phone:618-206-8816
Mailing Address - Fax:
Practice Address - Street 1:6 EAGLE CTR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1945
Practice Address - Country:US
Practice Address - Phone:618-206-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician