Provider Demographics
NPI:1437900529
Name:KOZENIESKI, MICHAEL JR
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KOZENIESKI
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1766 SOPHIAS DR APT 304
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6211
Mailing Address - Country:US
Mailing Address - Phone:941-391-7451
Mailing Address - Fax:
Practice Address - Street 1:1912 DAIRY RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-4046
Practice Address - Country:US
Practice Address - Phone:321-477-3905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician