Healthcare Provider Details

I. General information

NPI: 1003940560
Provider Name (Legal Business Name): STEVE WYSOCKI, PH.D., PC DBA ALTA LOMA PSYCHOLOGICAL ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 03/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9089 BASELINE RD. #200
RANCHO CUCAMONGA CA
91730-1295
US

IV. Provider business mailing address

9089 BASELINE RD. #200
RANCHO CUCAMONGA CA
91730-1295
US

V. Phone/Fax

Practice location:
  • Phone: 909-980-3567
  • Fax: 909-989-3932
Mailing address:
  • Phone: 909-980-3567
  • Fax: 909-989-3932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 6143
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 16794
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 28102
License Number StateCA

VIII. Authorized Official

Name: DR. STEVE R. WYSOCKI
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 909-980-3567