MEDICARE: IRENEUS JEROME KOZAK ATR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	221700000X	Art Therapist

General Provider Information

NPI Number	:	1417165119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRENEUS JEROME KOZAK ATR

Provider Business Mailing Address
First Line	:	28494 WALKER AVE
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48092-2543
Country	:	US
Telephone Number	:	734-657-2237
Fax Number	:

Provider Business Practice Location Address
First Line	:	28494 WALKER AVE
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48092-2543
Country	:	US
Telephone Number	:	734-657-2237
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	07/08/2007

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