Provider Demographics
NPI:1245721851
Name:CICHON, MACKENZIE J
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:J
Last Name:CICHON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:J
Other - Last Name:BANWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:1700 N DIVISION ST STE 200
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804
Practice Address - Country:US
Practice Address - Phone:563-324-2263
Practice Address - Fax:563-324-0719
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
092129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist