Healthcare Provider Details

I. General information

NPI: 1891275707
Provider Name (Legal Business Name): KELLEY KOZLOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4804 IROQUOIS AVE
SAN DIEGO CA
92117-6248
US

IV. Provider business mailing address

4804 IROQUOIS AVE
SAN DIEGO CA
92117-6248
US

V. Phone/Fax

Practice location:
  • Phone: 708-953-3144
  • Fax:
Mailing address:
  • Phone: 708-953-3144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: