Provider Demographics
NPI:1073848792
Name:ROTA, LAUREN JOHNSTON (LICAC)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:JOHNSTON
Last Name:ROTA
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 LINDEN ST
Mailing Address - Street 2:#3
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-5816
Mailing Address - Country:US
Mailing Address - Phone:508-653-5500
Mailing Address - Fax:
Practice Address - Street 1:317 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-1115
Practice Address - Country:US
Practice Address - Phone:508-653-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA203354171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist