Healthcare Provider Details

I. General information

NPI: 1619499951
Provider Name (Legal Business Name): KAITLIN REPKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 FOX TRAIL CT
LAKE FOREST IL
60045-2659
US

IV. Provider business mailing address

825 FOX TRAIL CT
LAKE FOREST IL
60045-2659
US

V. Phone/Fax

Practice location:
  • Phone: 847-909-4099
  • Fax:
Mailing address:
  • Phone: 847-909-4099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: