MEDICARE: KELEIGH NICOLE KOTZUR NCSP

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	103TS0200X	School Psychologist	34816	TX

General Provider Information

NPI Number	:	1558234278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELEIGH NICOLE KOTZUR NCSP

Provider Business Mailing Address
First Line	:	2303 WILDE ROCK WAY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-7144
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2303 WILDE ROCK WAY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-7144
Country	:	US
Telephone Number	:	361-652-5159
Fax Number	:

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

Provider Enumeration Date	:	09/29/2025
Last Update Date	:	09/29/2025

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