Healthcare Provider Details

I. General information

NPI: 1184263865
Provider Name (Legal Business Name): ALEJANDRO ULLOA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2019
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9890 COUNTY FARM RD STE 2
RIVERSIDE CA
92503-3678
US

IV. Provider business mailing address

7021 VALLEY WAY
RIVERSIDE CA
92509-3443
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-2499
  • Fax:
Mailing address:
  • Phone: 951-743-9585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW89930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: