Provider Demographics
NPI:1073981577
Name:SOTO, MARIELA JAZMIN (PSYD)
Entity type:Individual
Prefix:
First Name:MARIELA
Middle Name:JAZMIN
Last Name:SOTO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92-1118 OLANI ST APT 1
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-4223
Mailing Address - Country:US
Mailing Address - Phone:419-405-3191
Mailing Address - Fax:
Practice Address - Street 1:2817 ROCK MERRITT AVE
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-2003
Practice Address - Country:US
Practice Address - Phone:419-405-3191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007552103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical