MEDICARE: AMY KOZELKA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1083900450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY KOZELKA

Provider Business Mailing Address
First Line	:	5797 WEST FOUNTAIN CIRCLE DRIVE
Second Line	:
City	:	MASON
State	:	OH
Zip	:	45040
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7874 WOODGLEN DR
Second Line	:
City	:	WEST CHESTER
State	:	OH
Zip	:	45069-5831
Country	:	US
Telephone Number	:	507-450-9101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	07/12/2019

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