Healthcare Provider Details

I. General information

NPI: 1568865285
Provider Name (Legal Business Name): CASEY ROSE KOZLOV M.A., LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15811 AMBAUM BLVD SW STE 110
BURIEN WA
98166-3071
US

IV. Provider business mailing address

15811 AMBAUM BLVD SW STE 110
BURIEN WA
98166-3071
US

V. Phone/Fax

Practice location:
  • Phone: 610-739-9475
  • Fax:
Mailing address:
  • Phone: 610-739-9475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMG 60501427
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMG 60501427
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberCO 60502517
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLF60721682
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: