Provider Demographics
NPI:1710158175
Name:ESCOBAR, GINNA
Entity Type:Individual
Prefix:
First Name:GINNA
Middle Name:
Last Name:ESCOBAR
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 1:68 SUNDANCE DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4894
Mailing Address - Country:US
Mailing Address - Phone:909-629-1572
Mailing Address - Fax:
Practice Address - Street 1:1000 GOODRICH BLVD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90022-5103
Practice Address - Country:US
Practice Address - Phone:323-832-9795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45515106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist