Healthcare Provider Details

I. General information

NPI: 1295108579
Provider Name (Legal Business Name): TRICIA KOWALSKI OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N BRADLEY HWY
ROGERS CITY MI
49779
US

IV. Provider business mailing address

16174 RENWICK CIR W
PRESQUE ISLE MI
49777-8500
US

V. Phone/Fax

Practice location:
  • Phone: 989-734-2151
  • Fax:
Mailing address:
  • Phone: 989-766-0383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201009205
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: