Healthcare Provider Details

I. General information

NPI: 1003878604
Provider Name (Legal Business Name): SUSAN K ROTTY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8611 W POINT DOUGLAS RD S
COTTAGE GROVE MN
55016-4005
US

IV. Provider business mailing address

PO BOX 43 MR 10809
MINNEAPOLIS MN
55440-0043
US

V. Phone/Fax

Practice location:
  • Phone: 651-458-1884
  • Fax:
Mailing address:
  • Phone: 612-262-4813
  • Fax: 612-262-4194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1761
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: