Provider Demographics
NPI:1295341121
Name:ESCALANTE, LARISA IVANOVNA (LMFT)
Entity type:Individual
Prefix:MRS
First Name:LARISA
Middle Name:IVANOVNA
Last Name:ESCALANTE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:LARISA
Other - Middle Name:IVANOVNA
Other - Last Name:DOVBUSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95759-1554
Mailing Address - Country:US
Mailing Address - Phone:916-896-2768
Mailing Address - Fax:
Practice Address - Street 1:3960 INDUSTRIAL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-5024
Practice Address - Country:US
Practice Address - Phone:916-752-8965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140018101YM0800X
CA8105101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty