Healthcare Provider Details

I. General information

NPI: 1619360617
Provider Name (Legal Business Name): IVY REBECCA KOWALSKI LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IVY HUMPHREY

II. Dates (important events)

Enumeration Date: 03/15/2015
Last Update Date: 04/30/2022
Certification Date: 04/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 52ND ST SE
KENTWOOD MI
49508-6008
US

IV. Provider business mailing address

1100 52ND ST SE
KENTWOOD MI
49508-6008
US

V. Phone/Fax

Practice location:
  • Phone: 616-304-3095
  • Fax:
Mailing address:
  • Phone: 616-304-3095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401017786
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401017786
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: