Healthcare Provider Details

I. General information

NPI: 1447720552
Provider Name (Legal Business Name): LORI AYALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2018
Last Update Date: 11/01/2023
Certification Date: 10/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W HOSPITALITY LN STE 325
SAN BERNARDINO CA
92408-3249
US

IV. Provider business mailing address

325 W HOSPITALITY LN STE 110
SAN BERNARDINO CA
92408-3210
US

V. Phone/Fax

Practice location:
  • Phone: 951-708-1049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12737
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number118946
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: