Provider Demographics
NPI:1962960807
Name:KOWALCZYK, ROBIN (OTR)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:KOWALCZYK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34505 W 12 MILE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-3287
Mailing Address - Country:US
Mailing Address - Phone:734-343-7500
Mailing Address - Fax:
Practice Address - Street 1:34505 W 12 MILE RD STE 100
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3287
Practice Address - Country:US
Practice Address - Phone:734-343-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201002556225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201002556Medicaid