Provider Demographics
NPI:1609046820
Name:KOSZUT, STACEY (MS, CGC)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:
Last Name:KOSZUT
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3857
Mailing Address - Country:US
Mailing Address - Phone:800-975-4819
Mailing Address - Fax:
Practice Address - Street 1:360 CENTRAL AVE
Practice Address - Street 2:SUITE 1230
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3857
Practice Address - Country:US
Practice Address - Phone:800-975-4819
Practice Address - Fax:800-930-0691
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246.000048170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS