Basic Information
Provider Information | |||||||||
NPI: | 1487736005 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOWALSKI | ||||||||
FirstName: | MARYANNE | ||||||||
MiddleName: | LOUISE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 391 | ||||||||
Address2: |   | ||||||||
City: | SPRING LAKE | ||||||||
State: | MI | ||||||||
PostalCode: | 494560391 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2316839890 | ||||||||
FaxNumber: | 6168443006 | ||||||||
Practice Location | |||||||||
Address1: | 2700 BAKER ST FL 3 | ||||||||
Address2: |   | ||||||||
City: | MUSKEGON | ||||||||
State: | MI | ||||||||
PostalCode: | 494442157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2317371335 | ||||||||
FaxNumber: | 2317370534 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2006 | ||||||||
LastUpdateDate: | 01/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 6801065264 | MI | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 6801065264 | MI | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 6801065264 |   | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.