Healthcare Provider Details

I. General information

NPI: 1558234278
Provider Name (Legal Business Name): KELEIGH NICOLE KOTZUR NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 09/29/2025
Certification Date: 09/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 WILDE ROCK WAY
HOUSTON TX
77018-7144
US

IV. Provider business mailing address

2303 WILDE ROCK WAY
HOUSTON TX
77018-7144
US

V. Phone/Fax

Practice location:
  • Phone: 361-652-5159
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number34816
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: