Provider Demographics
NPI:1831607977
Name:SOTO, ILSE (MA)
Entity type:Individual
Prefix:
First Name:ILSE
Middle Name:
Last Name:SOTO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-2502
Mailing Address - Country:US
Mailing Address - Phone:760-691-9622
Mailing Address - Fax:442-999-5740
Practice Address - Street 1:510 CIVIC CENTER DR STE D
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-6169
Practice Address - Country:US
Practice Address - Phone:760-691-9622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
CA1-21-51963103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other