Provider Demographics
NPI:1104245695
Name:CISCHKE, FATEMA LYNN (COTA)
Entity type:Individual
Prefix:MRS
First Name:FATEMA
Middle Name:LYNN
Last Name:CISCHKE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:55196 HOLMES RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-4912
Mailing Address - Country:US
Mailing Address - Phone:574-310-9198
Mailing Address - Fax:
Practice Address - Street 1:1950 RIDGEDALE RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2243
Practice Address - Country:US
Practice Address - Phone:574-291-6722
Practice Address - Fax:574-291-8768
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001532A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant