Provider Demographics
NPI:1841490901
Name:KOMOSA, KEVIN A (LCSW)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:A
Last Name:KOMOSA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8221 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46403-1477
Mailing Address - Country:US
Mailing Address - Phone:219-938-9482
Mailing Address - Fax:
Practice Address - Street 1:8221 OAK AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-1477
Practice Address - Country:US
Practice Address - Phone:219-938-9482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002375A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker