Healthcare Provider Details

I. General information

NPI: 1245899962
Provider Name (Legal Business Name): FABIAN ESCOBEDO JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3255 WING ST
SAN DIEGO CA
92110-4638
US

IV. Provider business mailing address

3255 WING ST
SAN DIEGO CA
92110-4638
US

V. Phone/Fax

Practice location:
  • Phone: 619-980-5260
  • Fax:
Mailing address:
  • Phone: 619-980-5260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number109034
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: