Healthcare Provider Details

I. General information

NPI: 1275688392
Provider Name (Legal Business Name): JOHN S KOVALCHIK JR. LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 MAIN STREET
SPRINGFIELD MA
01104
US

IV. Provider business mailing address

147 NORMAN STREET
WEST SPRINGFIELD MA
01105
US

V. Phone/Fax

Practice location:
  • Phone: 413-736-0395
  • Fax: 413-734-1651
Mailing address:
  • Phone: 413-788-0929
  • Fax: 413-732-5362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113143
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: