Provider Demographics
NPI:1629640347
Name:ULLOA, TANIA LISETH
Entity type:Individual
Prefix:MS
First Name:TANIA
Middle Name:LISETH
Last Name:ULLOA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 DAWSON PL
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1002
Mailing Address - Country:US
Mailing Address - Phone:631-575-0822
Mailing Address - Fax:
Practice Address - Street 1:11835 QUEENS BLVD STE 400
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7211
Practice Address - Country:US
Practice Address - Phone:646-656-0164
Practice Address - Fax:718-520-7612
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator