Provider Demographics
NPI:1275002891
Name:ROTAN, KATHLEEN ANNE (MSED)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:ROTAN
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CHRISTOPHER CT
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-2635
Mailing Address - Country:US
Mailing Address - Phone:631-327-8010
Mailing Address - Fax:
Practice Address - Street 1:2 CHRISTOPHER CT
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-2635
Practice Address - Country:US
Practice Address - Phone:631-327-8010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1100305171174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist