Provider Demographics
NPI:1417165119
Name:KOZAK, IRENEUS JEROME (ATR)
Entity Type:Individual
Prefix:
First Name:IRENEUS
Middle Name:JEROME
Last Name:KOZAK
Suffix:
Gender:M
Credentials:ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28494 WALKER AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2543
Mailing Address - Country:US
Mailing Address - Phone:734-657-2237
Mailing Address - Fax:
Practice Address - Street 1:28494 WALKER AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2543
Practice Address - Country:US
Practice Address - Phone:734-657-2237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist