Healthcare Provider Details

I. General information

NPI: 1164369781
Provider Name (Legal Business Name): LISA KOTZEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 BRUNSON DR
CORAL GABLES FL
33146-2412
US

IV. Provider business mailing address

1100 S MIAMI AVE APT 4208
MIAMI FL
33130-4181
US

V. Phone/Fax

Practice location:
  • Phone: 305-284-3666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: