Provider Demographics
NPI:1356709190
Name:PROBASCO, MARK (DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PROBASCO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:
Practice Address - Street 1:727 W JOHNSON ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2015
Practice Address - Country:US
Practice Address - Phone:920-581-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist