Provider Demographics
NPI:1750326971
Name:COZZA, SCOTT ELMO (LCSW)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ELMO
Last Name:COZZA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 MISSION DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-5228
Mailing Address - Country:US
Mailing Address - Phone:707-658-0598
Mailing Address - Fax:707-778-0564
Practice Address - Street 1:159 KENTUCKY ST STE 10
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2324
Practice Address - Country:US
Practice Address - Phone:707-658-0598
Practice Address - Fax:707-778-0564
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS93751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACSW093750Medicaid
CAZZZ18569ZMedicare ID - Type UnspecifiedPPIN
CACSW093750Medicaid