Healthcare Provider Details

I. General information

NPI: 1083430185
Provider Name (Legal Business Name): KOTEL ATX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2024
Last Update Date: 12/07/2024
Certification Date: 12/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 W PARMER LN STE C175
AUSTIN TX
78727-4161
US

IV. Provider business mailing address

3001 BEE CAVES RD STE 220
AUSTIN TX
78746-5590
US

V. Phone/Fax

Practice location:
  • Phone: 855-204-2502
  • Fax:
Mailing address:
  • Phone: 512-777-2591
  • Fax: 512-777-3193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHIMENE PEREZ
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 904-750-3344