Provider Demographics
NPI:1619519600
Name:ROETLIN, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:ROETLIN
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 1:1930 LYNNCREST DR
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2714
Mailing Address - Country:US
Mailing Address - Phone:319-430-0698
Mailing Address - Fax:
Practice Address - Street 1:2350 OAKDALE BLVD
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-9702
Practice Address - Country:US
Practice Address - Phone:319-351-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA048141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical