Provider Demographics
NPI:1356030605
Name:KOZLOW, KAYLA ANN MARIE
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:ANN MARIE
Last Name:KOZLOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19832 NICKE ST APT 206
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-6104
Mailing Address - Country:US
Mailing Address - Phone:586-422-3210
Mailing Address - Fax:
Practice Address - Street 1:2013 EASTCASTLE DR SE STE B
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-8873
Practice Address - Country:US
Practice Address - Phone:616-888-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016514103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist