Healthcare Provider Details

I. General information

NPI: 1215459516
Provider Name (Legal Business Name): MAGGIE KOZMIN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2017
Last Update Date: 07/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 SKOKIE BLVD
NORTHBROOK IL
60062-2851
US

IV. Provider business mailing address

6723 PINE LN
CARPENTERSVILLE IL
60110-3431
US

V. Phone/Fax

Practice location:
  • Phone: 847-607-1589
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.009545
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: