Provider Demographics
NPI:1598983686
Name:DESOTO, MARTA (PHD)
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:
Last Name:DESOTO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39465 W 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1600
Mailing Address - Country:US
Mailing Address - Phone:248-859-3900
Mailing Address - Fax:888-483-0118
Practice Address - Street 1:39465 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1600
Practice Address - Country:US
Practice Address - Phone:248-859-3900
Practice Address - Fax:888-483-0118
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3776103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical