Provider Demographics
NPI:1346817160
Name:ANDERSON, MISTY LAYNE (RBT)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:LAYNE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:LAYNE
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3022 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3721
Mailing Address - Country:US
Mailing Address - Phone:618-967-1567
Mailing Address - Fax:
Practice Address - Street 1:3022 S PARK AVE
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3721
Practice Address - Country:US
Practice Address - Phone:618-967-1567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician