Provider Demographics
NPI:1720206634
Name:ULLOA, MANUEL I (CASAC)
Entity Type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:I
Last Name:ULLOA
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1309
Mailing Address - Country:US
Mailing Address - Phone:516-569-8490
Mailing Address - Fax:
Practice Address - Street 1:1727 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-4611
Practice Address - Country:US
Practice Address - Phone:212-694-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12905101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)