Provider Demographics
NPI:1053851691
Name:KOVANDA, WILLOW
Entity Type:Individual
Prefix:
First Name:WILLOW
Middle Name:
Last Name:KOVANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7480 DODSON PLZ APT 204
Mailing Address - Street 2:
Mailing Address - City:RALSTON
Mailing Address - State:NE
Mailing Address - Zip Code:68127-4291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 AMERICAN PKWY
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-6270
Practice Address - Country:US
Practice Address - Phone:402-339-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11127101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor