Healthcare Provider Details

I. General information

NPI: 1215037502
Provider Name (Legal Business Name): DANIEL JAMES KOZUBAL PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 NORTH LAKE ST STE 203
AURORA IL
60506
US

IV. Provider business mailing address

412 NORTH LAKE ST STE 203
AURORA IL
60506
US

V. Phone/Fax

Practice location:
  • Phone: 630-244-7000
  • Fax: 847-961-5730
Mailing address:
  • Phone: 630-244-7000
  • Fax: 847-961-5730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071003041
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: