Healthcare Provider Details

I. General information

NPI: 1760666895
Provider Name (Legal Business Name): COLLEEN M KOWALKE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 N 61ST AVE APT 2120
GLENDALE AZ
85302-6764
US

IV. Provider business mailing address

8150 N 61ST AVE APT 2120
GLENDALE AZ
85302-6764
US

V. Phone/Fax

Practice location:
  • Phone: 623-261-8770
  • Fax:
Mailing address:
  • Phone: 623-261-8770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC12790
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4545
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: