Provider Demographics
NPI:1902647688
Name:ESCOBEDO, THALIA BANDO (LCSW)
Entity type:Individual
Prefix:
First Name:THALIA
Middle Name:BANDO
Last Name:ESCOBEDO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 GEORGE BUSBEE PKWY NW APT 128
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-6849
Mailing Address - Country:US
Mailing Address - Phone:863-243-3792
Mailing Address - Fax:
Practice Address - Street 1:330 RESEARCH DR STE 210
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-2760
Practice Address - Country:US
Practice Address - Phone:706-705-2881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)