Provider Demographics
NPI:1700942331
Name:KOWALSKI, VICKI MICHELLE
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:MICHELLE
Last Name:KOWALSKI
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 1:3850 E STATE ROAD 64
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-9040
Mailing Address - Country:US
Mailing Address - Phone:941-748-2697
Mailing Address - Fax:
Practice Address - Street 1:3850 E STATE ROAD 64
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-9040
Practice Address - Country:US
Practice Address - Phone:941-748-2697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766314500Medicaid