Healthcare Provider Details

I. General information

NPI: 1295341121
Provider Name (Legal Business Name): LARISA IVANOVNA ESCALANTE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LARISA IVANOVNA DOVBUSH

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 07/21/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3960 INDUSTRIAL BLVD STE 200
WEST SACRAMENTO CA
95691-5024
US

IV. Provider business mailing address

PO BOX 1554
ELK GROVE CA
95759-1554
US

V. Phone/Fax

Practice location:
  • Phone: 916-752-8965
  • Fax:
Mailing address:
  • Phone: 916-896-2768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number140018
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: