Provider Demographics
NPI:1407079429
Name:ANDERSON, MOLLY LYNN
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-2843
Mailing Address - Country:US
Mailing Address - Phone:217-316-6794
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY CIR
Practice Address - Street 2:WESTERN ILLINOIS UNIVERSITY
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-1367
Practice Address - Country:US
Practice Address - Phone:309-298-2135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer