Provider Demographics
NPI:1093360190
Name:SOTO, SULLY ANETTE (LSW)
Entity Type:Individual
Prefix:
First Name:SULLY
Middle Name:ANETTE
Last Name:SOTO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 PARKWAY AVE
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08628-3000
Mailing Address - Country:US
Mailing Address - Phone:609-394-5157
Mailing Address - Fax:
Practice Address - Street 1:1239 PARKWAY AVE
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08628-3000
Practice Address - Country:US
Practice Address - Phone:609-394-5157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06340300104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty