Healthcare Provider Details

I. General information

NPI: 1184950883
Provider Name (Legal Business Name): JOHN MICHAEL KOWALSKI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 9TH AVENUE SUITE 220
LONGVIEW WA
98632
US

IV. Provider business mailing address

625 9TH AVE STE 220
LONGVIEW WA
98632-2465
US

V. Phone/Fax

Practice location:
  • Phone: 360-578-1188
  • Fax:
Mailing address:
  • Phone: 360-578-1188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60100317
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: