MEDICARE: DR. BRANDI ROTH PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	PSY 11855	CA

General Provider Information

NPI Number	:	1598896797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRANDI ROTH PH.D.

Provider Business Mailing Address
First Line	:	433 N CAMDEN DR
Second Line	:	SUITE 1128
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90210-4409
Country	:	US
Telephone Number	:	310-205-0615
Fax Number	:	310-275-3885

Provider Business Practice Location Address
First Line	:	433 N CAMDEN DR
Second Line	:	SUITE 1128
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90210-4409
Country	:	US
Telephone Number	:	310-205-0615
Fax Number	:	310-275-3885

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	07/08/2007

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