Healthcare Provider Details

I. General information

NPI: 1306981980
Provider Name (Legal Business Name): SUSAN ANN KOZAK MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26184 OUTER DR
LINCOLN PARK MI
48146-2084
US

IV. Provider business mailing address

42451 SALTZ RD
CANTON MI
48187-3457
US

V. Phone/Fax

Practice location:
  • Phone: 313-389-7546
  • Fax: 313-389-7515
Mailing address:
  • Phone: 313-389-7546
  • Fax: 313-389-7515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801020579
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: