Healthcare Provider Details

I. General information

NPI: 1669910097
Provider Name (Legal Business Name): MALLORY LYNN REIBER ATC, PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 W SOUTH ST
KEWANEE IL
61443-8354
US

IV. Provider business mailing address

822 PULASKI ST
LINCOLN IL
62656-2902
US

V. Phone/Fax

Practice location:
  • Phone: 217-871-9181
  • Fax:
Mailing address:
  • Phone: 217-871-9181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096004692
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160009119
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: