Provider Demographics
NPI:1093020521
Name:KOZAK, MELANIE M (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:M
Last Name:KOZAK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1785 AMBROSE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-7375
Mailing Address - Country:US
Mailing Address - Phone:618-401-8590
Mailing Address - Fax:
Practice Address - Street 1:2100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4701
Practice Address - Country:US
Practice Address - Phone:618-798-3135
Practice Address - Fax:618-798-3140
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist