Healthcare Provider Details

I. General information

NPI: 1902174691
Provider Name (Legal Business Name): DEBORAH KOZISEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 WATER ST
DANIELSON CT
06239-2838
US

IV. Provider business mailing address

13 WATER ST
DANIELSON CT
06239-2838
US

V. Phone/Fax

Practice location:
  • Phone: 860-779-5882
  • Fax: 860-779-5000
Mailing address:
  • Phone: 860-779-5882
  • Fax: 860-779-5000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1989
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: