Provider Demographics
NPI:1922536283
Name:KOZAK-HIETALA, CARRIE A (LISW)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:A
Last Name:KOZAK-HIETALA
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 WEST PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1138
Mailing Address - Country:US
Mailing Address - Phone:440-989-4900
Mailing Address - Fax:440-282-4779
Practice Address - Street 1:2115 WEST PARK DRIVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1138
Practice Address - Country:US
Practice Address - Phone:440-989-4900
Practice Address - Fax:440-282-4779
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0800557104100000X
OHI.2405256104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0256889Medicaid