Healthcare Provider Details

I. General information

NPI: 1356848683
Provider Name (Legal Business Name): ANDREA ULLOA SOBAMPO LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34324 YUCAIPA BLVD STE B-D
YUCAIPA CA
92399-2496
US

IV. Provider business mailing address

PO BOX 1286
NUEVO CA
92567-1286
US

V. Phone/Fax

Practice location:
  • Phone: 877-527-7227
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number165212
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: