Provider Demographics
NPI:1033205497
Name:KOVALESKI, MARK EDWIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWIN
Last Name:KOVALESKI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 TIOGA BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:APALACHIN
Mailing Address - State:NY
Mailing Address - Zip Code:13732-4150
Mailing Address - Country:US
Mailing Address - Phone:607-785-4156
Mailing Address - Fax:607-625-4438
Practice Address - Street 1:3 TIOGA BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:APALACHIN
Practice Address - State:NY
Practice Address - Zip Code:13732-4150
Practice Address - Country:US
Practice Address - Phone:607-785-4156
Practice Address - Fax:607-625-4438
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009697103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical