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General NPI Number Information
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NPI Number | 1912772906
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Entity Type | Individual
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Provider Name | MARK GATZKE
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Gender | Male
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Dates
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Enumeration Date | 11/20/2023
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Last Update Date | 11/20/2023
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Provider Practice Location Address
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Address Line | 4802 LONG SHOP RD
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City | BLACKSBURG
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State | VA
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Zip | 24060-0836
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Country | US
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Telephone | 540-632-9350
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Fax |
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Provider Business Mailing Address
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Address Line | 2727 ELECTRIC RD STE 103
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City | ROANOKE
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State | VA
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Zip | 24018-3500
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Country | US
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Telephone | 540-354-0911
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 0704013621
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License Number State | VA
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