Healthcare Provider Details

I. General information

NPI: 1497692586
Provider Name (Legal Business Name): LACEY ROTEM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5621 COUNTY ROAD 101
MINNETONKA MN
55345-4214
US

IV. Provider business mailing address

4212 ZOEBELLA WAY
VICTORIA MN
55318-2843
US

V. Phone/Fax

Practice location:
  • Phone: 952-401-6864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number462728
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: