Healthcare Provider Details

I. General information

NPI: 1083190524
Provider Name (Legal Business Name): ALYSSA KOZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13439 E 14 MILE RD
STERLING HEIGHTS MI
48312-6304
US

IV. Provider business mailing address

25775 W 10 MILE RD STE C
SOUTHFIELD MI
48033-4856
US

V. Phone/Fax

Practice location:
  • Phone: 586-685-0505
  • Fax: 586-685-0501
Mailing address:
  • Phone: 248-809-9941
  • Fax: 248-809-2480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501000205
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502005636
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: