Provider Demographics
NPI:1790806446
Name:SOUTO, SOFIA MARGARITA (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SOFIA
Middle Name:MARGARITA
Last Name:SOUTO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 E 10TH ST
Mailing Address - Street 2:APT. A4
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-2492
Mailing Address - Country:US
Mailing Address - Phone:305-733-6027
Mailing Address - Fax:
Practice Address - Street 1:200 S JORDAN AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-7002
Practice Address - Country:US
Practice Address - Phone:812-855-7348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005217A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891172000Medicaid