Provider Demographics
NPI:1679105563
Name:OH, MICHELLE THERESA
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:THERESA
Last Name:OH
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 1:13165 BRIARWOOD ST
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-7368
Mailing Address - Country:US
Mailing Address - Phone:714-752-0559
Mailing Address - Fax:
Practice Address - Street 1:14241 FIRESTONE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-5534
Practice Address - Country:US
Practice Address - Phone:714-752-0559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT107278106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty