Healthcare Provider Details

I. General information

NPI: 1952289266
Provider Name (Legal Business Name): REBECCA S KOLPAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA S MIKEL

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST
CHICAGO IL
60612-4795
US

IV. Provider business mailing address

1615 N WOOD ST APT 1F
CHICAGO IL
60622-1383
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 217-493-0473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: