Provider Demographics
NPI:1790248219
Name:MAS-SOTO, SANDY HERMOSA
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:HERMOSA
Last Name:MAS-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 1:4715 S HANAUER ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3742
Mailing Address - Country:US
Mailing Address - Phone:787-675-8868
Mailing Address - Fax:
Practice Address - Street 1:515 700 E
Practice Address - Street 2:SUITE 2A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102
Practice Address - Country:US
Practice Address - Phone:800-434-8923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-19-82935106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician