Provider Demographics
NPI:1386927986
Name:ROTH, ERICA M (PSYD)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:M
Last Name:ROTH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:M
Other - Last Name:EASTERLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1600 9TH ST
Mailing Address - Street 2:ROOM 140
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6414
Mailing Address - Country:US
Mailing Address - Phone:916-651-9475
Mailing Address - Fax:909-653-6376
Practice Address - Street 1:3102 E. HIGHLAND AVENUE
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369
Practice Address - Country:US
Practice Address - Phone:909-425-7679
Practice Address - Fax:909-425-6635
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24287103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical