Provider Demographics
NPI:1942824529
Name:KOWALCZYK, VICKY L (LMT)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:L
Last Name:KOWALCZYK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COURT ST
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-4005
Mailing Address - Country:US
Mailing Address - Phone:631-987-1783
Mailing Address - Fax:
Practice Address - Street 1:1 COURT ST
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-4005
Practice Address - Country:US
Practice Address - Phone:631-987-1783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-30
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019943-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist