Healthcare Provider Details

I. General information

NPI: 1023286077
Provider Name (Legal Business Name): KELLY KOWALEK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 GRAND AVE
MASSAPEQUA NY
11758-4905
US

IV. Provider business mailing address

2157 WANTAGH PARK DR
WANTAGH NY
11793-4100
US

V. Phone/Fax

Practice location:
  • Phone: 516-799-3203
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number067718-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: