Provider Demographics
NPI:1760423610
Name:TISKO, KATHLEEN (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:TISKO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3844 MARTHA LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-6126
Mailing Address - Country:US
Mailing Address - Phone:214-351-2299
Mailing Address - Fax:
Practice Address - Street 1:5930 LBJ FWY
Practice Address - Street 2:STE. 380
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6304
Practice Address - Country:US
Practice Address - Phone:214-351-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1018372225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F3964Medicare ID - Type Unspecified