Provider Demographics
NPI:1720401862
Name:KOZAK, MARY (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KOZAK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 WOODS RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-9409
Mailing Address - Country:US
Mailing Address - Phone:765-962-2349
Mailing Address - Fax:
Practice Address - Street 1:3260 OXFORD MILLVL RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-9430
Practice Address - Country:US
Practice Address - Phone:513-273-3633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-25
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP4957235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist