Provider Demographics
NPI:1104316538
Name:KOWALK, CARLIE (LMBT, CIMI)
Entity type:Individual
Prefix:MS
First Name:CARLIE
Middle Name:
Last Name:KOWALK
Suffix:
Gender:F
Credentials:LMBT, CIMI
Other - Prefix:MS
Other - First Name:CARLIE
Other - Middle Name:
Other - Last Name:LOVE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMBT, CIMI
Mailing Address - Street 1:491 KIMBERLY AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28804-2656
Mailing Address - Country:US
Mailing Address - Phone:828-338-8599
Mailing Address - Fax:
Practice Address - Street 1:491 KIMBERLY AVE APT 202
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28804-2656
Practice Address - Country:US
Practice Address - Phone:828-338-8599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4470225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty