Healthcare Provider Details

I. General information

NPI: 1770953580
Provider Name (Legal Business Name): ULISES IVAN LOZANO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

600 N ARROWHEAD AVE
SAN BERNARDINO CA
92401-1164
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-7320
  • Fax:
Mailing address:
  • Phone: 909-963-5355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW91195
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW91195
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number91195
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number125339
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: