Basic Information
| Provider Information | |||||||||
| NPI: | 1366606386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | PROTES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 WEST 5TH STREET | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148345015 | ||||||||
| FaxNumber: | 7145684527 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 WEST 5TH STREET | ||||||||
| Address2: | CYS | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148345015 | ||||||||
| FaxNumber: | 7145684527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2008 | ||||||||
| LastUpdateDate: | 09/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY11263 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.