Healthcare Provider Details

I. General information

NPI: 1982154118
Provider Name (Legal Business Name): MELISSA BOLIVAR ESCOBAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2016
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11845 W OLYMPIC BLVD STE 1050W
LOS ANGELES CA
90064-5046
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 888-588-8995
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: