Healthcare Provider Details

I. General information

NPI: 1922418177
Provider Name (Legal Business Name): KATIE KOWALCZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N 13TH ST
DECATUR IN
46733-1409
US

IV. Provider business mailing address

9161 N 100 W
DECATUR IN
46733-9740
US

V. Phone/Fax

Practice location:
  • Phone: 260-223-3342
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06004794A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: