Provider Demographics
NPI:1659729929
Name:REVAK, ANDREW PHILLIP (DPT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:PHILLIP
Last Name:REVAK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829-9138
Mailing Address - Country:US
Mailing Address - Phone:715-822-7300
Mailing Address - Fax:715-822-6142
Practice Address - Street 1:1051 WEST AVE
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-2299
Practice Address - Country:US
Practice Address - Phone:715-719-0662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13378-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist