Provider Demographics
NPI:1376511337
Name:PISCHKE, MARK (OT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PISCHKE
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 53RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-7565
Mailing Address - Country:US
Mailing Address - Phone:563-322-0970
Mailing Address - Fax:
Practice Address - Street 1:2300 53RD AVE STE LL02
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-7565
Practice Address - Country:US
Practice Address - Phone:563-322-0971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-004669225X00000X
IA01427225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA01427OtherIOWA LICENSE