Healthcare Provider Details

I. General information

NPI: 1093277519
Provider Name (Legal Business Name): DIANA ESCOBEDO LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 GRAND AVE
WAUKEGAN IL
60085-2321
US

IV. Provider business mailing address

3010 GRAND AVE
WAUKEGAN IL
60085-2321
US

V. Phone/Fax

Practice location:
  • Phone: 847-377-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178014482
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.013770
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: