Provider Demographics
NPI:1629737267
Name:ESCAMILLA, LIABETTE AILENE
Entity Type:Individual
Prefix:
First Name:LIABETTE
Middle Name:AILENE
Last Name:ESCAMILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIABETTE
Other - Middle Name:AILENE
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-3136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2622
Practice Address - Country:US
Practice Address - Phone:979-436-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist