Provider Demographics
NPI:1649754722
Name:KOZAK, ELIZABETH L (LBA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:KOZAK
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-6381
Mailing Address - Country:US
Mailing Address - Phone:606-425-2324
Mailing Address - Fax:
Practice Address - Street 1:600 BOGLE ST STE 2
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2885
Practice Address - Country:US
Practice Address - Phone:606-254-0495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY240343103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100572880Medicaid