Healthcare Provider Details

I. General information

NPI: 1659387348
Provider Name (Legal Business Name): BURTON RAABE M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5113 N EXECUTIVE DR SUITE 104
PEORIA IL
61614-4895
US

IV. Provider business mailing address

5113 N EXECUTIVE DR SUITE 104
PEORIA IL
61614-4895
US

V. Phone/Fax

Practice location:
  • Phone: 309-689-6700
  • Fax: 309-689-0774
Mailing address:
  • Phone: 309-689-6700
  • Fax: 309-689-0774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: