Healthcare Provider Details

I. General information

NPI: 1033353842
Provider Name (Legal Business Name): SUSAN KOWALCZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 BEVILLE RD STE G
SOUTH DAYTONA FL
32119-1712
US

IV. Provider business mailing address

27 WOOD RD
NORTH MIDDLESEX VT
05682-9783
US

V. Phone/Fax

Practice location:
  • Phone: 800-330-7711
  • Fax: 866-426-2811
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: