Provider Demographics
NPI:1376714105
Name:ROETH, SUSAN J (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:J
Last Name:ROETH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-2104
Mailing Address - Country:US
Mailing Address - Phone:719-634-4294
Mailing Address - Fax:
Practice Address - Street 1:1853 OCONNELL BLVD
Practice Address - Street 2:BLDG 1056, ROOM 9
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4055
Practice Address - Country:US
Practice Address - Phone:719-526-6823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical