Provider Demographics
NPI:1255630760
Name:THEROITH, SYREETA
Entity type:Individual
Prefix:
First Name:SYREETA
Middle Name:
Last Name:THEROITH
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 1:2800 E RIVERSIDE DR
Mailing Address - Street 2:246
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-7405
Mailing Address - Country:US
Mailing Address - Phone:319-290-4174
Mailing Address - Fax:
Practice Address - Street 1:3611 S HARBOR BLVD
Practice Address - Street 2:STE 100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-6928
Practice Address - Country:US
Practice Address - Phone:714-966-8670
Practice Address - Fax:714-434-0559
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-23
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103K00000X
NV225400000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst