Healthcare Provider Details

I. General information

NPI: 1487182101
Provider Name (Legal Business Name): ELENA KOZLOVA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 EL MONTE AVE STE B
MOUNTAIN VIEW CA
94040-2396
US

IV. Provider business mailing address

1061 EL MONTE AVE STE B
MOUNTAIN VIEW CA
94040-2396
US

V. Phone/Fax

Practice location:
  • Phone: 831-297-0567
  • Fax: 650-966-1807
Mailing address:
  • Phone: 831-297-0567
  • Fax: 650-966-1807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY29195
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: