Healthcare Provider Details

I. General information

NPI: 1699964304
Provider Name (Legal Business Name): GRISELDA P ESCOBEDO LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 4TH AVE E
TWIN FALLS ID
83301-6312
US

IV. Provider business mailing address

220 4TH AVE E
TWIN FALLS ID
83301-6312
US

V. Phone/Fax

Practice location:
  • Phone: 208-736-0695
  • Fax: 208-735-2482
Mailing address:
  • Phone: 208-736-0695
  • Fax: 208-735-2482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-3569
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: