Provider Demographics
NPI:1962231761
Name:ROTH, TREVOR H (LCSW)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:H
Last Name:ROTH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1364 HYLAND DR
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-4838
Mailing Address - Country:US
Mailing Address - Phone:570-460-7368
Mailing Address - Fax:
Practice Address - Street 1:1364 HYLAND DR
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-4838
Practice Address - Country:US
Practice Address - Phone:570-460-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099301381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical