Healthcare Provider Details

I. General information

NPI: 1417165119
Provider Name (Legal Business Name): IRENEUS JEROME KOZAK ATR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28494 WALKER AVE
WARREN MI
48092-2543
US

IV. Provider business mailing address

28494 WALKER AVE
WARREN MI
48092-2543
US

V. Phone/Fax

Practice location:
  • Phone: 734-657-2237
  • Fax:
Mailing address:
  • Phone: 734-657-2237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: