Provider Demographics
NPI:1386789832
Name:ROTERT, MARY MONIQUE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:MONIQUE
Last Name:ROTERT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40024 VIA XANTHE
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5568
Mailing Address - Country:US
Mailing Address - Phone:402-490-1662
Mailing Address - Fax:760-763-2222
Practice Address - Street 1:40024 VIA XANTHE
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5568
Practice Address - Country:US
Practice Address - Phone:402-490-1662
Practice Address - Fax:760-763-2222
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2022-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE 429103TC0700X
CA28409103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical