Provider Demographics
NPI:1255697942
Name:ULATE, MARI LISER (MA)
Entity type:Individual
Prefix:
First Name:MARI
Middle Name:LISER
Last Name:ULATE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MARI
Other - Middle Name:LISER
Other - Last Name:MONTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:855 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-2729
Mailing Address - Country:US
Mailing Address - Phone:909-983-2020
Mailing Address - Fax:
Practice Address - Street 1:1420 S MILLIKEN AVE STE 508
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-2337
Practice Address - Country:US
Practice Address - Phone:909-988-2418
Practice Address - Fax:909-988-4571
Is Sole Proprietor?:No
Enumeration Date:2012-04-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-1946482Medicaid