Provider Demographics
NPI:1457437170
Name:MATTESON, REBECCA S (LPT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:S
Last Name:MATTESON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:S
Other - Last Name:EMERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPT
Mailing Address - Street 1:PO BOX 72180
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-0180
Mailing Address - Country:US
Mailing Address - Phone:630-924-0156
Mailing Address - Fax:630-924-0462
Practice Address - Street 1:3115 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-3099
Practice Address - Country:US
Practice Address - Phone:630-924-0156
Practice Address - Fax:847-362-9486
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-013899225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
ILP00611624Medicare PIN
IL$$$$$$$$$001Medicaid
ILP00616802Medicare UPIN