Provider Demographics
NPI:1326497694
Name:SOTO MEDINA, ANA MARIA
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:MARIA
Last Name:SOTO MEDINA
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 1:19390 SW 124TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-6545
Mailing Address - Country:US
Mailing Address - Phone:786-370-1026
Mailing Address - Fax:
Practice Address - Street 1:19390 SW 124 AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177
Practice Address - Country:US
Practice Address - Phone:786-370-1026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-54242103K00000X
FLRBT-16-22533106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician