Provider Demographics
NPI:1760666895
Name:KOWALKE, COLLEEN M (PSYD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:KOWALKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8150 N 61ST AVE
Mailing Address - Street 2:APT 2120
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-6764
Mailing Address - Country:US
Mailing Address - Phone:623-261-8770
Mailing Address - Fax:
Practice Address - Street 1:8150 N 61ST AVE
Practice Address - Street 2:APT 2120
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-6764
Practice Address - Country:US
Practice Address - Phone:623-261-8770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC12790101YP2500X
AZ4545103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional