Provider Demographics
NPI:1023849494
Name:KOWALSKI, BLADE MORGAN
Entity type:Individual
Prefix:
First Name:BLADE
Middle Name:MORGAN
Last Name:KOWALSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9619 MARCI LN
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:IL
Mailing Address - Zip Code:60034-9513
Mailing Address - Country:US
Mailing Address - Phone:815-528-2179
Mailing Address - Fax:
Practice Address - Street 1:2000 LAKE AVE # 2
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-7401
Practice Address - Country:US
Practice Address - Phone:815-337-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160010187225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant