Healthcare Provider Details

I. General information

NPI: 1609118447
Provider Name (Legal Business Name): EDWARD KOZENY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FORTUNE LN
SAINT LOUIS MO
63122-6505
US

IV. Provider business mailing address

1 FORTUNE LN
SAINT LOUIS MO
63122-6505
US

V. Phone/Fax

Practice location:
  • Phone: 314-960-5829
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2008002921
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: