MEDICARE: KOZIOL PSYCHOLOGICAL SERVICES

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	103G00000X	Clinical Neuropsychologist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04672011	OTHER	IL	BLUE SHIELD

General Provider Information

NPI Number	:	1447377023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOZIOL PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 1457
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60078-1457
Country	:	US
Telephone Number	:	847-686-3643
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 N WILKE RD
Second Line	:	SUITE 160
City	:	ARLINGTON HTS
State	:	IL
Zip	:	60004-1278
Country	:	US
Telephone Number	:	847-686-3643
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LEONARD KOZIOL
Credential	:	PSYD
Telephone Number	:	847-686-3643

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	12/27/2007

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