Basic Information
| Provider Information | |||||||||
| NPI: | 1720124514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOTO | ||||||||
| FirstName: | AIDA | ||||||||
| MiddleName: | IRIS | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 N. MAITLAND AVE | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075392488 | ||||||||
| FaxNumber: | 4075392408 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 N. MAITLAND AVE | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075392488 | ||||||||
| FaxNumber: | 4075392408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 03/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OT3260 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 235Z00000X | OT3260 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 891150900 | 05 | FL | MEDICAID |