Healthcare Provider Details

I. General information

NPI: 1093406522
Provider Name (Legal Business Name): MARTHA JEANNE KOWALCZYK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3042 N KENMORE AVE APT 2S
CHICAGO IL
60657-9674
US

IV. Provider business mailing address

3042 N KENMORE AVE APT 2S
CHICAGO IL
60657-9674
US

V. Phone/Fax

Practice location:
  • Phone: 260-402-4300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.009474
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: