Provider Demographics
NPI:1700972551
Name:COZOLINO, SUSAN EVICH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:EVICH
Last Name:COZOLINO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:ANN
Other - Last Name:EVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 11503
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90295-7503
Mailing Address - Country:US
Mailing Address - Phone:213-639-4708
Mailing Address - Fax:
Practice Address - Street 1:3075 WILSHIRE BLVD
Practice Address - Street 2:8TH FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1205
Practice Address - Country:US
Practice Address - Phone:213-639-4708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17635103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical