=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023831674
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY ANN ROTEN MS, NHT, LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 11/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5841 WHITMORE LAKE RD STE C
-----------------------------------------------------
City | BRIGHTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48116-1991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-623-9249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10736 ODELL RD
-----------------------------------------------------
City | FOWLERVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48836-8233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-835-4671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Y00000X
-----------------------------------------------------
Taxonomy Name | Clinical Exercise Physiologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 7501015624
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------