Provider Demographics
NPI:1821620725
Name:ESCOBAR FLORES, VANESSA ESCOBAR
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ESCOBAR
Last Name:ESCOBAR FLORES
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 1:1172 E ELMA ST APT C
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-6722
Mailing Address - Country:US
Mailing Address - Phone:909-510-7901
Mailing Address - Fax:
Practice Address - Street 1:8350 ARCHIBALD AVE STE 110
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3670
Practice Address - Country:US
Practice Address - Phone:909-510-7901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106S00000XMedicaid