MEDICARE: MS. SUSAN J ROETH LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	975	CO

General Provider Information

NPI Number	:	1376714105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN J ROETH LCSW

Provider Business Mailing Address
First Line	:	652 N 30TH ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-2104
Country	:	US
Telephone Number	:	719-634-4294
Fax Number	:

Provider Business Practice Location Address
First Line	:	1853 OCONNELL BLVD
Second Line	:	BLDG 1056, ROOM 9
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4055
Country	:	US
Telephone Number	:	719-526-6823
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2008
Last Update Date	:	04/05/2011

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