Healthcare Provider Details

I. General information

NPI: 1154602530
Provider Name (Legal Business Name): MARY LYNNE KOZIOROWSKI CADC II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3340 KEMPER ST STE 103
SAN DIEGO CA
92110-4907
US

IV. Provider business mailing address

3340 KEMPER STREET SUITE 103
SAN DIEGO CA
92110
US

V. Phone/Fax

Practice location:
  • Phone: 619-224-1673
  • Fax: 619-224-2538
Mailing address:
  • Phone: 619-224-1673
  • Fax: 619-224-2538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA8392202 CADC II
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: