Individual
KELLEY KOZLOWSKI
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4804 IROQUOIS AVE, SAN DIEGO, CA 92117-6248
(708) 953-3144
Mailing address
4804 IROQUOIS AVE, SAN DIEGO, CA 92117-6248
(708) 953-3144
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
XOH846822315
BLUECROSS BLUESHIELD
IL
Enumeration date
08/20/2018
Last updated
08/20/2018
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