Healthcare Provider Details

I. General information

NPI: 1568153146
Provider Name (Legal Business Name): LUIS ANTHONY ESCOBAR CADC, LCDP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 BURNETT ST
PROVIDENCE RI
02907-2527
US

IV. Provider business mailing address

311 MAYFIELD AVE
CRANSTON RI
02920-2947
US

V. Phone/Fax

Practice location:
  • Phone: 401-433-8336
  • Fax:
Mailing address:
  • Phone: 401-433-8336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDP00938
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: