Healthcare Provider Details

I. General information

NPI: 1487999082
Provider Name (Legal Business Name): ELIZABETH SUSAN RAY KOWALIK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH SUSAN RAY KOWALIK ELIZABETH SUSAN RAY

II. Dates (important events)

Enumeration Date: 12/07/2012
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12977 N 40 DR STE 309
SAINT LOUIS MO
63141-8654
US

IV. Provider business mailing address

12977 N 40 DR STE 309
SAINT LOUIS MO
63141-8654
US

V. Phone/Fax

Practice location:
  • Phone: 314-246-0528
  • Fax:
Mailing address:
  • Phone: 314-246-0528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149024218
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2018036222
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: