Provider Demographics
NPI:1790050177
Name:ROTEN, LAURA ELIZABETH
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:ROTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ELIZABETH
Other - Last Name:SHINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:320 N CRAWFORD ST
Mailing Address - Street 2:
Mailing Address - City:WILLOWS
Mailing Address - State:CA
Mailing Address - Zip Code:95988-2326
Mailing Address - Country:US
Mailing Address - Phone:864-506-2622
Mailing Address - Fax:
Practice Address - Street 1:320 N CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:WILLOWS
Practice Address - State:CA
Practice Address - Zip Code:95988-2326
Practice Address - Country:US
Practice Address - Phone:864-506-2622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5478225100000X
CA304999261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist