Provider Demographics
NPI:1568008886
Name:KOWALKE, AVERY REVEN (LICENSED PROFESSIONA)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:REVEN
Last Name:KOWALKE
Suffix:
Gender:F
Credentials:LICENSED PROFESSIONA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 DOLORES DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2318
Mailing Address - Country:US
Mailing Address - Phone:608-669-5499
Mailing Address - Fax:
Practice Address - Street 1:6400 GISHOLT DR STE 100
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53713-4800
Practice Address - Country:US
Practice Address - Phone:608-669-5499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6438-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional