Provider Demographics
NPI:1770630683
Name:KOZLOWSKI, DEIRDRE LEE (LPC)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:LEE
Last Name:KOZLOWSKI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:944 N 37TH ST LOWR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3101
Mailing Address - Country:US
Mailing Address - Phone:414-933-7389
Mailing Address - Fax:
Practice Address - Street 1:6040 W LISBON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2116
Practice Address - Country:US
Practice Address - Phone:414-871-9111
Practice Address - Fax:414-871-9121
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI148-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391-95-700Medicaid