Healthcare Provider Details

I. General information

NPI: 1164778387
Provider Name (Legal Business Name): KEVIN M KOZIN LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 BEDFORD ST SUITE 22
LEXINGTON MA
02420-4646
US

IV. Provider business mailing address

14 SCHOOL ST # 2
WALTHAM MA
02452-5519
US

V. Phone/Fax

Practice location:
  • Phone: 781-325-1858
  • Fax: 617-249-1530
Mailing address:
  • Phone: 781-325-1858
  • Fax: 617-249-1530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number117008
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: