Healthcare Provider Details

I. General information

NPI: 1518682822
Provider Name (Legal Business Name): TRENTON KOWALCZUK LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7731 MENCHACA RD APT 1207
AUSTIN TX
78745-6067
US

IV. Provider business mailing address

7731 MENCHACA RD APT 1207
AUSTIN TX
78745-6067
US

V. Phone/Fax

Practice location:
  • Phone: 832-643-8678
  • Fax:
Mailing address:
  • Phone: 832-643-8678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number89782
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: