Provider Demographics
NPI:1851514442
Name:LOTT, STACY KOMMER (DPT)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:KOMMER
Last Name:LOTT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:MARIE
Other - Last Name:KOMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3152 SEBE ST
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-7679
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3055 EAGLE PARK DR
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-956-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23166225100000X
MI5501013320225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist