Provider Demographics
NPI:1114529294
Name:ROTH, RAVEN ALEXIS (MA, LAC, LPCC)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:ALEXIS
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA, LAC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7334 W OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-4986
Mailing Address - Country:US
Mailing Address - Phone:620-804-2039
Mailing Address - Fax:
Practice Address - Street 1:4401 S QUEBEC ST STE 200
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80237-2635
Practice Address - Country:US
Practice Address - Phone:620-804-2039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0001568101YA0400X
COLPC.0016845101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)