Healthcare Provider Details

I. General information

NPI: 1619123262
Provider Name (Legal Business Name): BRETT WAPOTISH DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 N RANDALL RD
LAKE IN THE HILLS IL
60156-5903
US

IV. Provider business mailing address

8937 GRAND AVE
RIVER GROVE IL
60171-3603
US

V. Phone/Fax

Practice location:
  • Phone: 847-854-8219
  • Fax: 847-854-8278
Mailing address:
  • Phone: 708-453-1354
  • Fax: 708-453-2679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-016612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: