Provider Demographics
NPI:1285356337
Name:WOMBAT MENTAL HEALTH SERVICES A LCSW PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:WOMBAT MENTAL HEALTH SERVICES A LCSW PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:ESCARENO
Authorized Official - Suffix:
Authorized Official - Credentials:DSW, LSCW
Authorized Official - Phone:840-999-1767
Mailing Address - Street 1:9431 HAVEN AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5878
Mailing Address - Country:US
Mailing Address - Phone:840-999-1767
Mailing Address - Fax:
Practice Address - Street 1:9431 HAVEN AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5878
Practice Address - Country:US
Practice Address - Phone:840-999-1767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-15
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty