=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144138546
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN G KOZAK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2026
-----------------------------------------------------
Last Update Date | 08/28/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 HUNTLEY RD
-----------------------------------------------------
City | OLD LYME
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-434-5524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 NEWENT RD
-----------------------------------------------------
City | LISBON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06351-2927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-710-8036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 2415
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------