Healthcare Provider Details

I. General information

NPI: 1104693076
Provider Name (Legal Business Name): CYNTHIA KOZAK RD, CDCES, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 12/11/2023
Certification Date: 12/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 NEW RD
AVON CT
06001-3163
US

IV. Provider business mailing address

209 NEW RD
AVON CT
06001-3163
US

V. Phone/Fax

Practice location:
  • Phone: 860-280-8049
  • Fax:
Mailing address:
  • Phone: 860-280-8049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberR632989
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: