Healthcare Provider Details

I. General information

NPI: 1790308765
Provider Name (Legal Business Name): MICHELLE LILLIAN KOZIMOR M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 05/25/2020
Certification Date: 05/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 E MONTEREY WAY
PHOENIX AZ
85012-2753
US

IV. Provider business mailing address

45 E MONTEREY WAY # 100
PHOENIX AZ
85012-2753
US

V. Phone/Fax

Practice location:
  • Phone: 480-641-1165
  • Fax:
Mailing address:
  • Phone: 480-641-1165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: