Provider Demographics
NPI:1699593772
Name:SOTO, ALEXA TATYANNA (LSW)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:TATYANNA
Last Name:SOTO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 W FRY ST APT 4R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-5350
Mailing Address - Country:US
Mailing Address - Phone:312-757-9808
Mailing Address - Fax:
Practice Address - Street 1:1803 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5105
Practice Address - Country:US
Practice Address - Phone:773-658-9272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-28
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.114445104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker