Provider Demographics
NPI:1568865285
Name:KOZLOV, CASEY ROSE (MA, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:CASEY
Middle Name:ROSE
Last Name:KOZLOV
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15811 AMBAUM BLVD SW STE 110
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-3071
Mailing Address - Country:US
Mailing Address - Phone:610-739-9475
Mailing Address - Fax:
Practice Address - Street 1:15811 AMBAUM BLVD SW STE 110
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3071
Practice Address - Country:US
Practice Address - Phone:610-739-9475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG 60501427101YM0800X, 106H00000X
WACO 60502517390200000X
WALF60721682106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program