Provider Demographics
NPI:1669762084
Name:ANDERSON, MOLLY BEA (M A)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:BEA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 APACHE WAY
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:IL
Mailing Address - Zip Code:61535-9409
Mailing Address - Country:US
Mailing Address - Phone:309-387-6404
Mailing Address - Fax:
Practice Address - Street 1:119A N PARKWAY DR
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-3932
Practice Address - Country:US
Practice Address - Phone:309-642-6763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist