Provider Demographics
NPI:1780238527
Name:KOTSENBURG, KRISTEN
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:
Last Name:KOTSENBURG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9613 LYRIC LN
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-6407
Mailing Address - Country:US
Mailing Address - Phone:307-640-6967
Mailing Address - Fax:
Practice Address - Street 1:2801 PARKLAWN DR STE 201
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4229
Practice Address - Country:US
Practice Address - Phone:405-733-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1114099355Medicaid