Healthcare Provider Details

I. General information

NPI: 1013451434
Provider Name (Legal Business Name): KATHERINE KOWALCZIK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

397 BRIDGE ST
BROOKLYN NY
11201-5292
US

IV. Provider business mailing address

19712 MACARTHUR BLVD STE 110
IRVINE CA
92612-2407
US

V. Phone/Fax

Practice location:
  • Phone: 646-904-8155
  • Fax:
Mailing address:
  • Phone: 646-904-8155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1050001
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number108007
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number092564
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: