Provider Demographics
NPI:1750846358
Name:KOZAK, ROBERT JAMES (BCABA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JAMES
Last Name:KOZAK
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:MR
Other - First Name:ROBERT
Other - Middle Name:JAMES
Other - Last Name:BRUTOFSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1831 GOLDEN EAGLE WAY STE 34
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4340
Mailing Address - Country:US
Mailing Address - Phone:904-579-4779
Mailing Address - Fax:888-501-3580
Practice Address - Street 1:1831 GOLDEN EAGLE WAY STE 34
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4340
Practice Address - Country:US
Practice Address - Phone:904-579-4779
Practice Address - Fax:888-501-3580
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-18-9211103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst