Provider Demographics
NPI:1710457700
Name:ESCAMILLA, MICHELLE SUZANNE YANDELL
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SUZANNE YANDELL
Last Name:ESCAMILLA
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 1:220 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CA
Mailing Address - Zip Code:95386-9202
Mailing Address - Country:US
Mailing Address - Phone:209-918-4385
Mailing Address - Fax:
Practice Address - Street 1:1335 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-2838
Practice Address - Country:US
Practice Address - Phone:209-609-7841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician