Healthcare Provider Details

I. General information

NPI: 1508341793
Provider Name (Legal Business Name): AMY C KOWALSKI LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY C VANACKER

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/11/2024
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2542 NE COURTNEY DR.
BEND OR
97701
US

IV. Provider business mailing address

56 SE 11TH ST
MADRAS OR
97741
US

V. Phone/Fax

Practice location:
  • Phone: 541-241-2127
  • Fax: 541-460-7854
Mailing address:
  • Phone: 541-728-8453
  • Fax: 541-460-7854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number23966
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: