Healthcare Provider Details

I. General information

NPI: 1730292673
Provider Name (Legal Business Name): CANDELARIO ESCAMILLA JR. LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 E. CALTON RD. STE. 109
LAREDO TX
78041
US

IV. Provider business mailing address

710 DELLWOOD DR.
LAREDO TX
78045
US

V. Phone/Fax

Practice location:
  • Phone: 956-791-0335
  • Fax: 956-791-0374
Mailing address:
  • Phone: 956-723-1675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10349
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: