=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205286440
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOZIOL THERAPY AND COACHING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2016
-----------------------------------------------------
Last Update Date | 06/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1159 WILMETTE AVE SUITE 9
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091-2649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-372-5996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5348 N CUMBERLAND AVE APT. 502
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60656-1409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-372-5996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WIOLETA KOZIOL
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 773-372-5996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149.017528
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------