Provider Demographics
NPI:1154084788
Name:KOZAL, NICOLE LYN (LLMSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYN
Last Name:KOZAL
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2864 ASHMUN ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-3740
Mailing Address - Country:US
Mailing Address - Phone:906-635-6075
Mailing Address - Fax:
Practice Address - Street 1:2864 ASHMUN ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3740
Practice Address - Country:US
Practice Address - Phone:906-635-6075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511104621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical