Basic Information
| Provider Information | |||||||||
| NPI: | 1720281389 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOTO | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7369 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923750369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093357067 | ||||||||
| FaxNumber: | 9097922045 | ||||||||
| Practice Location | |||||||||
| Address1: | 34324 YUCAIPA BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | YUCAIPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923992496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097901300 | ||||||||
| FaxNumber: | 9097979687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | S0407170928 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 4385 | 01 | CA | SIMON STAFF NUMBER | OTHER |