=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225992852
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORINE ULLOA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2025
-----------------------------------------------------
Last Update Date | 12/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34764 BIRCH RD
-----------------------------------------------------
City | BARSTOW
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92311-7237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-548-7649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34756 BIRCH RD
-----------------------------------------------------
City | BARSTOW
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92311-7237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-548-7649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Psychologist
-----------------------------------------------------
License Number | C6556567
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------