Provider Demographics
NPI:1083862841
Name:REPA, MATTHEW SCOTT (ATC)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:SCOTT
Last Name:REPA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9326 KEDVALE AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1421
Mailing Address - Country:US
Mailing Address - Phone:847-269-9326
Mailing Address - Fax:
Practice Address - Street 1:2401 RAVINE WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7645
Practice Address - Country:US
Practice Address - Phone:847-724-4791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0026022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer