Healthcare Provider Details

I. General information

NPI: 1356588370
Provider Name (Legal Business Name): MRS. DEIDRE CHRISTINE KOWALEWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 S MAIN ST SUITE 220
JAMESTOWN NY
14701-6626
US

IV. Provider business mailing address

168 TEMPLE ST
FREDONIA NY
14063-1757
US

V. Phone/Fax

Practice location:
  • Phone: 716-488-2322
  • Fax: 716-488-2574
Mailing address:
  • Phone: 716-672-7624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number014517-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: