Healthcare Provider Details

I. General information

NPI: 1649550799
Provider Name (Legal Business Name): JUDITH MARIE KOWALIK LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 SMYTH RD
MANCHESTER NH
03104-7007
US

IV. Provider business mailing address

718 SMYTH ROAD
MANCHESTER NH
03104
US

V. Phone/Fax

Practice location:
  • Phone: 603-624-4366
  • Fax:
Mailing address:
  • Phone: 603-624-4366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1316
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: