Basic Information
Provider Information | |||||||||
NPI: | 1275872996 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOTO-AYBAR | ||||||||
FirstName: | INDIRA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 28 WATER ST APT 407 | ||||||||
Address2: |   | ||||||||
City: | WORCESTER | ||||||||
State: | MA | ||||||||
PostalCode: | 016045017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4133020728 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 85 SAINT GEORGE RD | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 011043333 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137322120 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/01/2013 | ||||||||
LastUpdateDate: | 02/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
ID Information
ID | Type | State | Issuer | Description | 12529 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 042622756 | 01 | MA | COMMONWEALTH CARE ALLIANCE | OTHER | 71756 | 01 | MA | TUFTS | OTHER | 1022610 | 01 | MA | BEACON | OTHER | 997303 | 01 | MA | NETWORK HEALTH | OTHER | 1303295 | 05 | MA |   | MEDICAID | 1303295 | 01 | MA | MBHP | OTHER | 8443 | 01 | MA | BMC/BEACON | OTHER |