Healthcare Provider Details

I. General information

NPI: 1194918722
Provider Name (Legal Business Name): ELISA ESCAMILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 08/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W MAIN ST
SAN JACINTO CA
92583-4121
US

IV. Provider business mailing address

102 W MAIN ST
SAN JACINTO CA
92583-4121
US

V. Phone/Fax

Practice location:
  • Phone: 951-487-8883
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: