Provider Demographics
NPI:1477565091
Name:SOTO, MARICELA A
Entity Type:Individual
Prefix:
First Name:MARICELA
Middle Name:A
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 1:69175 RAMON RD STE A
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-3344
Mailing Address - Country:US
Mailing Address - Phone:760-321-6776
Mailing Address - Fax:858-634-6956
Practice Address - Street 1:69175 RAMON RD STE A
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-3344
Practice Address - Country:US
Practice Address - Phone:760-321-6776
Practice Address - Fax:858-634-6956
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71006953103TB0200X
CA19456103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL71006953OtherPSYCHOLOGIST LISCENSE