Provider Demographics
NPI:1609815026
Name:MATUSOFF, MICHELLE JOANNE
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:JOANNE
Last Name:MATUSOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5267 WARNER AVE. #108
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-4517
Mailing Address - Country:US
Mailing Address - Phone:949-275-5225
Mailing Address - Fax:714-377-9531
Practice Address - Street 1:3101 W COAST HWY
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4001
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15421103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY154210Medicaid
CAPSY154211OtherLOS ANGELES MEDICAL
CAPSY154210Medicaid
CAWCP15421AMedicare ID - Type UnspecifiedALL OTHER COUNTIES
CAWCP15421BMedicare ID - Type UnspecifiedLA COUNTY