Provider Demographics
NPI:1396209763
Name:ESENBOCK, BABY VIVIAN LEIGH
Entity Type:Individual
Prefix:
First Name:BABY VIVIAN
Middle Name:LEIGH
Last Name:ESENBOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1394 WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-8801
Mailing Address - Country:US
Mailing Address - Phone:707-476-3417
Mailing Address - Fax:
Practice Address - Street 1:901 O ST STE C
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-5789
Practice Address - Country:US
Practice Address - Phone:707-497-9335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician