Provider Demographics
NPI:1124814108
Name:KOZLOWSKI, KELLY RYAN (MS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RYAN
Last Name:KOZLOWSKI
Suffix:
Gender:
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38345 30TH ST E STE C2
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-4982
Mailing Address - Country:US
Mailing Address - Phone:661-418-2871
Mailing Address - Fax:
Practice Address - Street 1:435 YALE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4340
Practice Address - Country:US
Practice Address - Phone:661-418-2871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119397106H00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1407660251Medicaid
CA1871324046Medicaid