Provider Demographics
NPI:1265771992
Name:MISCHKE, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MISCHKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:GAGSTETTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5000 BLUE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-9213
Mailing Address - Country:US
Mailing Address - Phone:406-251-2323
Mailing Address - Fax:406-251-2999
Practice Address - Street 1:150 E SPRUCE ST
Practice Address - Street 2:STE A
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4504
Practice Address - Country:US
Practice Address - Phone:406-549-0064
Practice Address - Fax:406-543-2999
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019592225100000X
MTPTP-PT-LIC-9281225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist