Provider Demographics
NPI:1912945296
Name:KOZICK, GARY (MSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:KOZICK
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 ANTONIA DR
Mailing Address - Street 2:
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-2403
Mailing Address - Country:US
Mailing Address - Phone:518-374-1392
Mailing Address - Fax:
Practice Address - Street 1:1201 NOTT ST
Practice Address - Street 2:SUITE 306
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2589
Practice Address - Country:US
Practice Address - Phone:518-588-8346
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR039653-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY362383OtherMVP PROVIDER NUMBER
NYN226S1OtherEMPIRE BC/BS MAGELLAN
NY000403575001OtherBLUE SHIELD OF NORTHEAST
NY10072214OtherCDPHP PROVIDER NUMBER
NY476643OtherVALUEOPTIONS PROVIDER NUM
NY7333576OtherNEW YORK EMPIRE PLAN GHI
NYDD4088Medicare ID - Type UnspecifiedPROVIDER NUMBER
NYP78472Medicare UPIN