Healthcare Provider Details

I. General information

NPI: 1689199416
Provider Name (Legal Business Name): KOLBY KOCZANOWSKI LPMT, MT-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 08/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12060 ETRIS RD # 200
ROSWELL GA
30075-1463
US

IV. Provider business mailing address

230 HALEY PASS
ALPHARETTA GA
30004-7537
US

V. Phone/Fax

Practice location:
  • Phone: 678-701-1203
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License NumberMUT000174
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: