Provider Demographics
NPI:1508341793
Name:KOWALSKI, AMY C (LMT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:C
Last Name:KOWALSKI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:C
Other - Last Name:VANACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:56 SE 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741
Mailing Address - Country:US
Mailing Address - Phone:541-728-8453
Mailing Address - Fax:541-460-7854
Practice Address - Street 1:2542 NE COURTNEY DR.
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:541-241-2127
Practice Address - Fax:541-460-7854
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23966225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist