Provider Demographics
NPI:1073336145
Name:ESTABROOK, GRAYDON E (PHD SCHOOL PSYCH)
Entity type:Individual
Prefix:
First Name:GRAYDON
Middle Name:E
Last Name:ESTABROOK
Suffix:
Gender:M
Credentials:PHD SCHOOL PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E NORTH DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6595
Mailing Address - Country:US
Mailing Address - Phone:812-330-7700
Mailing Address - Fax:
Practice Address - Street 1:315 E NORTH DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6595
Practice Address - Country:US
Practice Address - Phone:812-330-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN663394103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool