Healthcare Provider Details

I. General information

NPI: 1013512367
Provider Name (Legal Business Name): DAVID KOZAK MSW, LCSW-A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 N MAIN ST STE 216
ROXBORO NC
27573-5343
US

IV. Provider business mailing address

399 LOUISIANA DR
RAEFORD NC
28376-6017
US

V. Phone/Fax

Practice location:
  • Phone: 336-322-0657
  • Fax:
Mailing address:
  • Phone: 910-585-9047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP014528
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: