Healthcare Provider Details

I. General information

NPI: 1477389518
Provider Name (Legal Business Name): KYLE KOWALSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/13/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 HARRISON AVE
BOSTON MA
02118-2905
US

IV. Provider business mailing address

753 BOYLSTON ST APT 2
CHESTNUT HILL MA
02467-1488
US

V. Phone/Fax

Practice location:
  • Phone: 617-396-4404
  • Fax:
Mailing address:
  • Phone: 603-568-3268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: