Healthcare Provider Details

I. General information

NPI: 1336021567
Provider Name (Legal Business Name): CARLY NICOLE KOWALEWSKI MC, NCC, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1198 LAKEWOOD RD
TOMS RIVER NJ
08753-2243
US

IV. Provider business mailing address

1009 SHIP AVE
BEACHWOOD NJ
08722-2321
US

V. Phone/Fax

Practice location:
  • Phone: 732-605-6364
  • Fax:
Mailing address:
  • Phone: 732-228-0789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number37AC00887300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: