Provider Demographics
NPI:1629390695
Name:KOWALCZYK, MOIRA L (OT/L)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:L
Last Name:KOWALCZYK
Suffix:
Gender:M
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 131
Mailing Address - Street 2:
Mailing Address - City:LAHASKA
Mailing Address - State:PA
Mailing Address - Zip Code:18931
Mailing Address - Country:US
Mailing Address - Phone:908-894-4854
Mailing Address - Fax:
Practice Address - Street 1:551 WEST LANCASTER AVENUE
Practice Address - Street 2:
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041
Practice Address - Country:US
Practice Address - Phone:610-525-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00240700225X00000X
PAOC012248225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist