Healthcare Provider Details

I. General information

NPI: 1275544082
Provider Name (Legal Business Name): MALGORZATA KOWALCZYK LMT, PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GOSHA KOWALCZYK LMT,PTA

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 05/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5266 STATION WAY
SARASOTA FL
34233-3232
US

IV. Provider business mailing address

5266 STATION WAY
SARASOTA FL
34233-3232
US

V. Phone/Fax

Practice location:
  • Phone: 561-809-5812
  • Fax:
Mailing address:
  • Phone: 561-809-5812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA52217
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: