Healthcare Provider Details

I. General information

NPI: 1891538161
Provider Name (Legal Business Name): RENOVO COUNSELING SERVICES, A LICENSED CLINICAL SOCIAL WORKER CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 LA MART DR STE 106
RIVERSIDE CA
92507-5991
US

IV. Provider business mailing address

5005 LA MART DR STE 106
RIVERSIDE CA
92507-5991
US

V. Phone/Fax

Practice location:
  • Phone: 951-602-3373
  • Fax:
Mailing address:
  • Phone: 951-602-3373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JACOB ANTHONY ESCOBEDO
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LCSW
Phone: 951-602-3373