Provider Demographics
NPI:1194847350
Name:FORTIER, MICHELLE AIMEE (PHD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:AIMEE
Last Name:FORTIER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S MAIN ST
Mailing Address - Street 2:SUITE 940
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4509
Mailing Address - Country:US
Mailing Address - Phone:714-480-0067
Mailing Address - Fax:714-480-0733
Practice Address - Street 1:1 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92697-0001
Practice Address - Country:US
Practice Address - Phone:949-824-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22312103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent