MEDICARE: CHAMROEUN NICOLE LEISEY COTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	215390	TX

General Provider Information

NPI Number	:	1063145035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAMROEUN NICOLE LEISEY COTA

Provider Business Mailing Address
First Line	:	2310 ELDRIDGE PKWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-5254
Country	:	US
Telephone Number	:	281-658-1337
Fax Number	:

Provider Business Practice Location Address
First Line	:	2310 ELDRIDGE PKWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-5254
Country	:	US
Telephone Number	:	281-558-3900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2022
Last Update Date	:	07/06/2022

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