Healthcare Provider Details

I. General information

NPI: 1417862673
Provider Name (Legal Business Name): ERIC ROTTMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11630 FULTON ST E
LOWELL MI
49331-9426
US

IV. Provider business mailing address

1707 EDGEWOOD AVE SE
GRAND RAPIDS MI
49506-5110
US

V. Phone/Fax

Practice location:
  • Phone: 616-481-3784
  • Fax:
Mailing address:
  • Phone: 616-617-2602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451025241
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: