Healthcare Provider Details

I. General information

NPI: 1912667528
Provider Name (Legal Business Name): KIM ANN KOZINA-EVANOSKI LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

77 E 1ST ST
CORNING NY
14830-2715
US

IV. Provider business mailing address

77 E 1ST ST
CORNING NY
14830-2715
US

V. Phone/Fax

Practice location:
  • Phone: 607-936-1771
  • Fax: 607-936-2648
Mailing address:
  • Phone: 607-936-1771
  • Fax: 607-936-2648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number044384
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: