Provider Demographics
NPI:1942712450
Name:ROTH, PEYTON
Entity Type:Individual
Prefix:
First Name:PEYTON
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4856 INNOVATION DR
Mailing Address - Street 2:STE B
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5540
Mailing Address - Country:US
Mailing Address - Phone:970-494-4200
Mailing Address - Fax:970-613-4475
Practice Address - Street 1:4856 INNOVATION DR
Practice Address - Street 2:STE B
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5540
Practice Address - Country:US
Practice Address - Phone:970-494-4200
Practice Address - Fax:970-613-4475
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0002300101YA0400X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)