MEDICARE: MS. SOFIA KAZULKINA MA, LLP

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	103T00000X	Psychologist	6301014551	MI

General Provider Information

NPI Number	:	1578839346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SOFIA KAZULKINA MA, LLP

Provider Business Mailing Address
First Line	:	PO BOX 915
Second Line	:
City	:	YPSILANTI
State	:	MI
Zip	:	48197-0915
Country	:	US
Telephone Number	:	734-544-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 HOGBACK RD
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48105-9732
Country	:	US
Telephone Number	:	734-973-4863
Fax Number	:

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

Provider Enumeration Date	:	03/27/2012
Last Update Date	:	03/27/2012

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