Provider Demographics
NPI:1336954890
Name:ROTH COURTNEY, SUZANNE
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:ROTH COURTNEY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11775 WADSWORTH BLVD APT 12303
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2842
Mailing Address - Country:US
Mailing Address - Phone:720-936-1580
Mailing Address - Fax:
Practice Address - Street 1:6545 W 44TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4749
Practice Address - Country:US
Practice Address - Phone:720-257-2142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-11
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23109101YP2500X
CO2391171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty