Provider Demographics
NPI:1710096383
Name:KEPRTA, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KEPRTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3764
Mailing Address - Country:US
Mailing Address - Phone:847-733-0832
Mailing Address - Fax:
Practice Address - Street 1:4200 W PETERSON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6074
Practice Address - Country:US
Practice Address - Phone:773-545-6885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL70009697OtherLICENSE#