Basic Information
| Provider Information | |||||||||
| NPI: | 1326635889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTHFORK | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPCC, LAC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8407 N BRYANT STREET | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034877776 | ||||||||
| FaxNumber: | 3034877868 | ||||||||
| Practice Location | |||||||||
| Address1: | 8407 N BRYANT STREET | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034877776 | ||||||||
| FaxNumber: | 3034877868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2020 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/31/2020 | ||||||||
| NPIReactivationDate: | 03/04/2021 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPCC.0018000 | CO | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | ACD.0002088 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.