Provider Demographics
NPI:1003444134
Name:ROTRAMEL, STACY LYN
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYN
Last Name:ROTRAMEL
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 1:10 W SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60112-4072
Mailing Address - Country:US
Mailing Address - Phone:815-757-6263
Mailing Address - Fax:
Practice Address - Street 1:10 W SOUTH AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:IL
Practice Address - Zip Code:60112-4072
Practice Address - Country:US
Practice Address - Phone:815-757-6263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician