Healthcare Provider Details

I. General information

NPI: 1609815026
Provider Name (Legal Business Name): DR. MICHELLE JOANNE MATUSOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 W COAST HWY
NEWPORT BEACH CA
92663-4001
US

IV. Provider business mailing address

5267 WARNER AVE. #108
HUNTINGTON BEACH CA
92649-4517
US

V. Phone/Fax

Practice location:
  • Phone: 800-257-8715
  • Fax: 800-819-1655
Mailing address:
  • Phone: 949-275-5225
  • Fax: 714-377-9531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY15421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: