Healthcare Provider Details

I. General information

NPI: 1003399460
Provider Name (Legal Business Name): NICOLE S KOZILSKY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 SARATOGA AVE
AMSTERDAM NY
12010-1846
US

IV. Provider business mailing address

9 GLENWOOD RD
MENANDS NY
12204-2406
US

V. Phone/Fax

Practice location:
  • Phone: 518-843-4932
  • Fax:
Mailing address:
  • Phone: 518-268-9614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number086981
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: