Provider Demographics
NPI:1063145035
Name:LEISEY, CHAMROEUN NICOLE (COTA)
Entity type:Individual
Prefix:
First Name:CHAMROEUN
Middle Name:NICOLE
Last Name:LEISEY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 ELDRIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-5254
Mailing Address - Country:US
Mailing Address - Phone:281-658-1337
Mailing Address - Fax:
Practice Address - Street 1:2310 ELDRIDGE PKWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-5254
Practice Address - Country:US
Practice Address - Phone:281-558-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215390224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant