Healthcare Provider Details

I. General information

NPI: 1437641784
Provider Name (Legal Business Name): SAMANTHA ESCOBAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2018
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N EUCLID AVE
ONTARIO CA
91762-2729
US

IV. Provider business mailing address

13717 STANFORD CT
FONTANA CA
92336-3434
US

V. Phone/Fax

Practice location:
  • Phone: 909-983-2020
  • Fax:
Mailing address:
  • Phone: 909-319-2848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number105992
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number105992
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: