Healthcare Provider Details

I. General information

NPI: 1972054294
Provider Name (Legal Business Name): JUSTIN KOZAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5710 N BROADWAY ST
CHICAGO IL
60660-4302
US

IV. Provider business mailing address

2423 OAK ST
BLUE ISLAND IL
60406-2032
US

V. Phone/Fax

Practice location:
  • Phone: 224-500-4197
  • Fax:
Mailing address:
  • Phone: 708-829-5673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.010578
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: