Healthcare Provider Details

I. General information

NPI: 1417232042
Provider Name (Legal Business Name): MARY KOWALSKI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY STACHOWIAK

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W JEFFERSON BLVD
SOUTH BEND IN
46601-1512
US

IV. Provider business mailing address

315 W JEFFERSON BLVD
SOUTH BEND IN
46601-1512
US

V. Phone/Fax

Practice location:
  • Phone: 574-968-9660
  • Fax: 574-246-0171
Mailing address:
  • Phone: 574-968-9660
  • Fax: 574-246-0171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34001904A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: