MEDICARE: COLLEEN M KOWALKE PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC12790	AZ
2	103TC0700X	Clinical Psychologist	4545	AZ

General Provider Information

NPI Number	:	1760666895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN M KOWALKE PSYD

Provider Business Mailing Address
First Line	:	8150 N 61ST AVE
Second Line	:	APT 2120
City	:	GLENDALE
State	:	AZ
Zip	:	85302-6764
Country	:	US
Telephone Number	:	623-261-8770
Fax Number	:

Provider Business Practice Location Address
First Line	:	8150 N 61ST AVE
Second Line	:	APT 2120
City	:	GLENDALE
State	:	AZ
Zip	:	85302-6764
Country	:	US
Telephone Number	:	623-261-8770
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/26/2007
Last Update Date	:	02/10/2015

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