Healthcare Provider Details

I. General information

NPI: 1285609420
Provider Name (Legal Business Name): STACI M ROTH OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E MAIN ST STE G
SAINT CHARLES IL
60174-2431
US

IV. Provider business mailing address

38W125 HENRICKSEN RD
SAINT CHARLES IL
60175-5471
US

V. Phone/Fax

Practice location:
  • Phone: 630-880-0993
  • Fax:
Mailing address:
  • Phone: 630-217-0834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056013526
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: