Provider Demographics
NPI:1366757049
Name:MOZOLIK, AMY RENEE (PSYD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:RENEE
Last Name:MOZOLIK
Suffix:
Gender:F
Credentials:PSYD
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 230812
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99523-0812
Mailing Address - Country:US
Mailing Address - Phone:907-306-6760
Mailing Address - Fax:844-513-4092
Practice Address - Street 1:401 E FIREWEED LN STE 201
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2100
Practice Address - Country:US
Practice Address - Phone:907-306-6760
Practice Address - Fax:844-513-4092
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI533-226101YP2500X
AKPSY P 660103T00000X
AK732101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1579978Medicaid
AKK165631Medicare PIN