Provider Demographics
NPI:1225649197
Name:SOTO, DOMONIQUE E
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:E
Last Name:SOTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6676 AVENUE 416 SPC 4
Mailing Address - Street 2:
Mailing Address - City:DINUBA
Mailing Address - State:CA
Mailing Address - Zip Code:93618-9131
Mailing Address - Country:US
Mailing Address - Phone:559-305-1637
Mailing Address - Fax:
Practice Address - Street 1:144 S L ST
Practice Address - Street 2:
Practice Address - City:DINUBA
Practice Address - State:CA
Practice Address - Zip Code:93618-2323
Practice Address - Country:US
Practice Address - Phone:559-591-1576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA1107961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health