Healthcare Provider Details

I. General information

NPI: 1437900529
Provider Name (Legal Business Name): MICHAEL KOZENIESKI JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1912 DAIRY RD
WEST MELBOURNE FL
32904-4046
US

IV. Provider business mailing address

1766 SOPHIAS DR APT 304
MELBOURNE FL
32940-6211
US

V. Phone/Fax

Practice location:
  • Phone: 321-477-3905
  • Fax:
Mailing address:
  • Phone: 941-391-7451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: