Provider Demographics
NPI:1629104245
Name:SANTIAGO-KOZMON, ANNETTE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:
Last Name:SANTIAGO-KOZMON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1301
Mailing Address - Country:US
Mailing Address - Phone:860-356-0828
Mailing Address - Fax:860-356-0829
Practice Address - Street 1:17 CEDAR STREET
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-2224
Practice Address - Country:US
Practice Address - Phone:860-356-0828
Practice Address - Fax:860-356-0829
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0061371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004261236Medicaid