Provider Demographics
NPI:1740925833
Name:ROTH, BRANDON J (LPC)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:J
Last Name:ROTH
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 BOWLINE CT
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3116
Mailing Address - Country:US
Mailing Address - Phone:208-317-5875
Mailing Address - Fax:
Practice Address - Street 1:306 BOWLINE CT
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3116
Practice Address - Country:US
Practice Address - Phone:208-317-5875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0018181101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional