Healthcare Provider Details

I. General information

NPI: 1093564064
Provider Name (Legal Business Name): KATHLEEN MARY KOWALKE LPC, CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 RIVERSIDE DR
GREEN BAY WI
54301-2316
US

IV. Provider business mailing address

2800 PARKRIDGE AVE
MARINETTE WI
54143-1529
US

V. Phone/Fax

Practice location:
  • Phone: 920-272-8220
  • Fax: 651-323-2648
Mailing address:
  • Phone: 262-352-4010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11075-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: