Provider Demographics
NPI:1114529294
Name:ROTH, RAVEN ALEXIS (MA, LPC, LAC)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:ALEXIS
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA, LPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 WADSWORTH BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4653
Mailing Address - Country:US
Mailing Address - Phone:970-310-3406
Mailing Address - Fax:
Practice Address - Street 1:4350 WADSWORTH BLVD STE 250
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4653
Practice Address - Country:US
Practice Address - Phone:970-310-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0016845101YP2500X, 101YM0800X
COACD.0001568101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)