Provider Demographics
NPI:1114432317
Name:ROTH, LAURA JO (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JO
Last Name:ROTH
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:JO
Other - Last Name:ROTH-SHOFRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYCHOLOGIST
Mailing Address - Street 1:90 VANTIS DR UNIT 2070
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2507
Mailing Address - Country:US
Mailing Address - Phone:949-300-4623
Mailing Address - Fax:949-300-4623
Practice Address - Street 1:4300 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2011
Practice Address - Country:US
Practice Address - Phone:562-294-4024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-10
Last Update Date:2017-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12823103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical