Provider Demographics
NPI:1285148841
Name:KOCISZEWSKI, GARY DONALD JR
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:DONALD
Last Name:KOCISZEWSKI
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 1:4920 TRASKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1059
Mailing Address - Country:US
Mailing Address - Phone:727-214-8041
Mailing Address - Fax:
Practice Address - Street 1:9405 BARNSTEAD LN
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-4302
Practice Address - Country:US
Practice Address - Phone:727-967-2809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-18
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-20-11136106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst