Healthcare Provider Details

I. General information

NPI: 1104457746
Provider Name (Legal Business Name): MELINDA SUE KOCZOROWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

123 22ND ST
TOLEDO OH
43604-2706
US

IV. Provider business mailing address

6629 W CENTRAL AVE
TOLEDO OH
43617-1098
US

V. Phone/Fax

Practice location:
  • Phone: 419-475-4449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: