Healthcare Provider Details

I. General information

NPI: 1366256901
Provider Name (Legal Business Name): ALYSSA HOLLY KOWALCZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1452 BLOOMINGDALE AVE
VALRICO FL
33596-6110
US

IV. Provider business mailing address

7125 HIDEAWAY TRL
NEW PORT RICHEY FL
34655-4063
US

V. Phone/Fax

Practice location:
  • Phone: 813-616-4004
  • Fax:
Mailing address:
  • Phone: 813-520-2961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT25895
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: