Healthcare Provider Details

I. General information

NPI: 1730353442
Provider Name (Legal Business Name): MARY SUSAN KOWALSKI PTA,CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SMITH AVE N
SAINT PAUL MN
55102-2344
US

IV. Provider business mailing address

27 ROUND LAKE TRL
LITTLE CANADA MN
55117-6014
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-7288
  • Fax: 651-241-7177
Mailing address:
  • Phone: 651-484-8480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberJULY 2008
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: