Provider Demographics
NPI:1447857164
Name:SOTO, ANTHONY RENE
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:RENE
Last Name:SOTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17882 SE MCLOUGHLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-6103
Mailing Address - Country:US
Mailing Address - Phone:503-353-9415
Mailing Address - Fax:503-353-9409
Practice Address - Street 1:17882 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-6103
Practice Address - Country:US
Practice Address - Phone:503-353-9415
Practice Address - Fax:503-353-9409
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OR22-06-10438101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program