Provider Demographics
NPI:1780429795
Name:ESCALANTE, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:ESCALANTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9827 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:92316-2022
Mailing Address - Country:US
Mailing Address - Phone:310-873-7906
Mailing Address - Fax:
Practice Address - Street 1:16823 ARROW BLVD
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3803
Practice Address - Country:US
Practice Address - Phone:909-355-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist