Healthcare Provider Details

I. General information

NPI: 1265809123
Provider Name (Legal Business Name): ELAINE ESTACIO LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 W 161ST ST
LAWNDALE CA
90260-2732
US

IV. Provider business mailing address

PO BOX 1133
LAWNDALE CA
90260-6033
US

V. Phone/Fax

Practice location:
  • Phone: 808-372-6331
  • Fax:
Mailing address:
  • Phone: 808-372-6331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1854
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: