Healthcare Provider Details

I. General information

NPI: 1568008886
Provider Name (Legal Business Name): AVERY REVEN KOWALKE LICENSED PROFESSIONA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 GISHOLT DR STE 100
MONONA WI
53713-4800
US

IV. Provider business mailing address

1914 DOLORES DR
MADISON WI
53716-2318
US

V. Phone/Fax

Practice location:
  • Phone: 608-669-5499
  • Fax:
Mailing address:
  • Phone: 608-669-5499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6438-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: