Healthcare Provider Details

I. General information

NPI: 1518577501
Provider Name (Legal Business Name): LARISSA ANN KOZENY DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8660 GRANT RD
SAINT LOUIS MO
63123-1044
US

IV. Provider business mailing address

452 MISSION BAY DR
WILDWOOD MO
63040-1522
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-3939
  • Fax:
Mailing address:
  • Phone: 314-518-1844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2007011441
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: