Provider Demographics
NPI:1023831674
Name:ROTEN, STACEY ANN (MS, NHT, LMT)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ANN
Last Name:ROTEN
Suffix:
Gender:F
Credentials:MS, NHT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10736 ODELL RD
Mailing Address - Street 2:
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-8233
Mailing Address - Country:US
Mailing Address - Phone:248-835-4671
Mailing Address - Fax:
Practice Address - Street 1:5841 WHITMORE LAKE RD STE C
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1991
Practice Address - Country:US
Practice Address - Phone:810-623-9249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Y00000X
MI7501015624225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist