MEDICARE: KYLEE M KOWALSKI DLLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6351004933	MI

General Provider Information

NPI Number	:	1902655350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLEE M KOWALSKI DLLP

Provider Business Mailing Address
First Line	:	300 68TH ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49548-6927
Country	:	US
Telephone Number	:	616-455-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	17325 VAN WAGONER RD
Second Line	:
City	:	SPRING LAKE
State	:	MI
Zip	:	49456-9702
Country	:	US
Telephone Number	:	616-847-5145
Fax Number	:	616-827-4700

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2024
Last Update Date	:	05/26/2026

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