Provider Demographics
NPI:1174900922
Name:KOZAK, MICHELLE (MSPT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KOZAK
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 193
Mailing Address - Street 2:1192 ELTON RD
Mailing Address - City:FARMERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14060-0193
Mailing Address - Country:US
Mailing Address - Phone:716-676-5053
Mailing Address - Fax:
Practice Address - Street 1:1192 ELTON RD
Practice Address - Street 2:
Practice Address - City:FARMERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14060-0193
Practice Address - Country:US
Practice Address - Phone:716-676-5053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014325-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist