MEDICARE: MARIELA JAZMIN SOTO PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	0810007552	VA

General Provider Information

NPI Number	:	1073981577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIELA JAZMIN SOTO PSYD

Provider Business Mailing Address
First Line	:	2817 ROCK MERITT AVE
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-0001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2817 ROCK MERRITT AVE
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-2003
Country	:	US
Telephone Number	:	419-405-3191
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2015
Last Update Date	:	03/25/2026

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