Provider Demographics
NPI:1881100451
Name:SOTO, MICAHEL ANTHONY (LPT)
Entity type:Individual
Prefix:
First Name:MICAHEL
Middle Name:ANTHONY
Last Name:SOTO
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:ANTHONY
Other - Last Name:SOTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPT
Mailing Address - Street 1:1517 W GARVEY AVE N
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2138
Mailing Address - Country:US
Mailing Address - Phone:626-962-6061
Mailing Address - Fax:626-962-4471
Practice Address - Street 1:1517 W GARVEY AVE N
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2138
Practice Address - Country:US
Practice Address - Phone:626-962-6061
Practice Address - Fax:626-962-4471
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT40658167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician