Healthcare Provider Details

I. General information

NPI: 1770201709
Provider Name (Legal Business Name): CORY E KOWALSKI PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CORY E HARRISON

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

IV. Provider business mailing address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

V. Phone/Fax

Practice location:
  • Phone: 909-894-7455
  • Fax:
Mailing address:
  • Phone: 909-894-7455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number33356
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: