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General NPI Number Information
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NPI Number | 1194847350
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Entity Type | Individual
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Provider Name | MICHELLE AIMEE FORTIER PHD
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Gender | Female
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Dates
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Enumeration Date | 04/06/2007
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Last Update Date | 10/08/2009
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Provider Practice Location Address
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Address Line | 1 MEDICAL PLAZA DR
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City | IRVINE
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State | CA
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Zip | 92697-0001
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Country | US
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Telephone | 949-824-7246
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Fax |
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Provider Business Mailing Address
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Address Line | 505 S MAIN ST SUITE 940
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City | ORANGE
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State | CA
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Zip | 92868-4509
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Country | US
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Telephone | 714-480-0067
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Fax | 714-480-0733
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | PSY22312
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License Number State | CA
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