Healthcare Provider Details

I. General information

NPI: 1225992852
Provider Name (Legal Business Name): CORINE ULLOA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34764 BIRCH RD
BARSTOW CA
92311-7237
US

IV. Provider business mailing address

34756 BIRCH RD
BARSTOW CA
92311-7237
US

V. Phone/Fax

Practice location:
  • Phone: 760-548-7649
  • Fax:
Mailing address:
  • Phone: 760-548-7649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberC6556567
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: