Provider Demographics
NPI:1720281389
Name:SOTO, PAMELA MARIE
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:MARIE
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:PO BOX 7369
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-0369
Mailing Address - Country:US
Mailing Address - Phone:909-335-7067
Mailing Address - Fax:909-792-2045
Practice Address - Street 1:34324 YUCAIPA BLVD STE B
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2496
Practice Address - Country:US
Practice Address - Phone:909-790-1300
Practice Address - Fax:909-797-9687
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAS0407170928101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4385OtherSIMON STAFF NUMBER