Provider Demographics
NPI:1518472398
Name:KOZLOV, ELISSA KATE (PHD)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:KATE
Last Name:KOZLOV
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E 75TH ST
Mailing Address - Street 2:2H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-3314
Mailing Address - Country:US
Mailing Address - Phone:914-715-3012
Mailing Address - Fax:
Practice Address - Street 1:1745 BROADWAY FL 17
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4642
Practice Address - Country:US
Practice Address - Phone:212-851-8100
Practice Address - Fax:212-537-0102
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022411103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty