Provider Demographics
NPI:1003399460
Name:KOZILSKY, NICOLE S
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:KOZILSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MENANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12204-2406
Mailing Address - Country:US
Mailing Address - Phone:518-268-9614
Mailing Address - Fax:
Practice Address - Street 1:140 SARATOGA AVE
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-1846
Practice Address - Country:US
Practice Address - Phone:518-843-4932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0869811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical