Healthcare Provider Details

I. General information

NPI: 1538443932
Provider Name (Legal Business Name): JOLIE KOWAL MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 BEACON HILL RD
PORT WASHINGTON NY
11050-3032
US

IV. Provider business mailing address

42 BEACON HILL RD
PORT WASHINGTON NY
11050-3032
US

V. Phone/Fax

Practice location:
  • Phone: 516-205-3270
  • Fax:
Mailing address:
  • Phone: 516-205-3270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: