Healthcare Provider Details

I. General information

NPI: 1639577109
Provider Name (Legal Business Name): SANDRA ESCOBEDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2014
Last Update Date: 11/04/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W VICTORIA ST
GARDENA CA
90248-3523
US

IV. Provider business mailing address

3909 E 56TH ST
MAYWOOD CA
90270-2703
US

V. Phone/Fax

Practice location:
  • Phone: 310-715-2020
  • Fax:
Mailing address:
  • Phone: 323-979-3834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW63218
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number99513
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: