Provider Demographics
NPI:1003940560
Name:STEVE WYSOCKI, PH.D., PC DBA ALTA LOMA PSYCHOLOGICAL ASSOC
Entity Type:Organization
Organization Name:STEVE WYSOCKI, PH.D., PC DBA ALTA LOMA PSYCHOLOGICAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:R
Authorized Official - Last Name:WYSOCKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:909-980-3567
Mailing Address - Street 1:9089 BASELINE RD.
Mailing Address - Street 2:#200
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1295
Mailing Address - Country:US
Mailing Address - Phone:909-980-3567
Mailing Address - Fax:909-989-3932
Practice Address - Street 1:9089 BASELINE RD.
Practice Address - Street 2:#200
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1295
Practice Address - Country:US
Practice Address - Phone:909-980-3567
Practice Address - Fax:909-989-3932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 6143103TC0700X
CALCS 167941041C0700X
CAMFC 28102106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty