Healthcare Provider Details

I. General information

NPI: 1912945296
Provider Name (Legal Business Name): GARY KOZICK M.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NOTT ST SUITE 306
SCHENECTADY NY
12308-2589
US

IV. Provider business mailing address

2512 ANTONIA DR
NISKAYUNA NY
12309-2403
US

V. Phone/Fax

Practice location:
  • Phone: 518-588-8346
  • Fax:
Mailing address:
  • Phone: 518-374-1392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR039653-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: