Provider Demographics
NPI:1730353442
Name:KOWALSKI, MARY SUSAN (PTA,CLT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:SUSAN
Last Name:KOWALSKI
Suffix:
Gender:F
Credentials:PTA,CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 ROUND LAKE TRL
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-6014
Mailing Address - Country:US
Mailing Address - Phone:651-484-8480
Mailing Address - Fax:
Practice Address - Street 1:333 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2344
Practice Address - Country:US
Practice Address - Phone:651-241-7288
Practice Address - Fax:651-241-7177
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNJULY 2008225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant