Provider Demographics
NPI:1003465659
Name:ESCOBEDO, EVA BERNADETTE (EVA)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:BERNADETTE
Last Name:ESCOBEDO
Suffix:
Gender:F
Credentials:EVA
Other - Prefix:
Other - First Name:EVA
Other - Middle Name:BERNADETTE
Other - Last Name:SORES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4635 W 18TH PL
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4869
Mailing Address - Country:US
Mailing Address - Phone:909-952-4106
Mailing Address - Fax:
Practice Address - Street 1:4660 VIEWRIDGE AVE STE 100A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1638
Practice Address - Country:US
Practice Address - Phone:909-952-4106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
225400000X
CA14965-RAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$Medicaid