Provider Demographics
NPI:1023132719
Name:ROTH, MELISSA J (MA, MFT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27951 SMYTH DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-4048
Mailing Address - Country:US
Mailing Address - Phone:661-993-3893
Mailing Address - Fax:661-251-4814
Practice Address - Street 1:27951 SMYTH DR
Practice Address - Street 2:SUITE 108
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-4048
Practice Address - Country:US
Practice Address - Phone:661-993-3893
Practice Address - Fax:661-251-4814
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 38252106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist