Healthcare Provider Details

I. General information

NPI: 1285117002
Provider Name (Legal Business Name): SUSANNE KOWALSKY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSANNE MARIE BERNERO

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 N KILBOURN AVE
CHICAGO IL
60630-2624
US

IV. Provider business mailing address

5025 N KILBOURN AVE
CHICAGO IL
60630-2624
US

V. Phone/Fax

Practice location:
  • Phone: 773-343-7096
  • Fax:
Mailing address:
  • Phone: 773-343-7096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: