Healthcare Provider Details

I. General information

NPI: 1003580671
Provider Name (Legal Business Name): KELLEY ESCAMILLA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 07/30/2023
Certification Date: 07/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22994 EL TORO RD STE 109
LAKE FOREST CA
92630-4961
US

IV. Provider business mailing address

PO BOX 27822
SANTA ANA CA
92799-7822
US

V. Phone/Fax

Practice location:
  • Phone: 714-886-7366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101874
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: