Healthcare Provider Details

I. General information

NPI: 1689123796
Provider Name (Legal Business Name): COLIN KOWLESSAR LMHC,CASAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2016
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17732 129TH AVE
JAMAICA NY
11434-5822
US

IV. Provider business mailing address

17732 129TH AVE
JAMAICA NY
11434-5822
US

V. Phone/Fax

Practice location:
  • Phone: 718-300-1018
  • Fax:
Mailing address:
  • Phone: 718-300-1018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number007386
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number23490
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: