Provider Demographics
NPI:1366606386
Name:ROTH, MICHELLE PROTES (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:PROTES
Last Name:ROTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:405 WEST 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701
Mailing Address - Country:US
Mailing Address - Phone:714-834-5015
Mailing Address - Fax:714-568-4527
Practice Address - Street 1:405 WEST 5TH STREET
Practice Address - Street 2:CYS
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701
Practice Address - Country:US
Practice Address - Phone:714-834-5015
Practice Address - Fax:714-568-4527
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11263103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical