Healthcare Provider Details

I. General information

NPI: 1114432317
Provider Name (Legal Business Name): LAURA JO ROTH PSYCHOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA JO ROTH-SHOFRON PSYCHOLOGIST

II. Dates (important events)

Enumeration Date: 12/10/2017
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81673 AVENIDA ALTURAS
INDIO CA
92203-7782
US

IV. Provider business mailing address

81673 AVENIDA ALTURAS
INDIO CA
92203-7782
US

V. Phone/Fax

Practice location:
  • Phone: 949-300-4623
  • Fax: 949-300-4623
Mailing address:
  • Phone: 949-300-4623
  • Fax: 949-300-4623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY12823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: