Provider Demographics
NPI:1326635889
Name:ROTHFORK, KYLE (LPCC, LAC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:ROTHFORK
Suffix:
Gender:M
Credentials:LPCC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 CARMELLO CIR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-7951
Mailing Address - Country:US
Mailing Address - Phone:864-328-7046
Mailing Address - Fax:
Practice Address - Street 1:1455 DIXON AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-8879
Practice Address - Country:US
Practice Address - Phone:303-443-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2023-03-22
Deactivation Date:2020-12-31
Deactivation Code:
Reactivation Date:2021-03-04
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0018000101YP2500X
COACD.0002088101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional