Provider Demographics
NPI:1013528462
Name:REBOLLAR, ANICA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ANICA
Middle Name:
Last Name:REBOLLAR
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 WOODBURY CIR
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5602
Mailing Address - Country:US
Mailing Address - Phone:224-321-9902
Mailing Address - Fax:
Practice Address - Street 1:31 S SEYMOUR AVE STE H
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-3652
Practice Address - Country:US
Practice Address - Phone:224-252-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.025123225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist