Healthcare Provider Details

I. General information

NPI: 1083846364
Provider Name (Legal Business Name): PATRICIA KOWALCHUK OTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6050 ST.JOHNS AVE., SUITE A
PALATKA FL
32177
US

IV. Provider business mailing address

6841 BIG SKY LN
MELROSE FL
32666-8932
US

V. Phone/Fax

Practice location:
  • Phone: 386-312-0022
  • Fax:
Mailing address:
  • Phone: 352-494-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA8018
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: