MEDICARE: MARICELA A SOTO

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	103TB0200X	Cognitive & Behavioral Psychologist	71006953	IL
2	103TC0700X	Clinical Psychologist	19456	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	71006953	OTHER	IL	PSYCHOLOGIST LISCENSE

General Provider Information

NPI Number	:	1477565091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARICELA A SOTO

Provider Business Mailing Address
First Line	:	69175 RAMON RD STE A
Second Line	:
City	:	CATHEDRAL CITY
State	:	CA
Zip	:	92234-3344
Country	:	US
Telephone Number	:	760-321-6776
Fax Number	:	858-634-6956

Provider Business Practice Location Address
First Line	:	69175 RAMON RD STE A
Second Line	:
City	:	CATHEDRAL CITY
State	:	CA
Zip	:	92234-3344
Country	:	US
Telephone Number	:	760-321-6776
Fax Number	:	858-634-6956

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

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	11/15/2019

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