Provider Demographics
NPI:1134486087
Name:VELASCO, LUIS ALBERTO (MA,IMF)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:ALBERTO
Last Name:VELASCO
Suffix:
Gender:M
Credentials:MA,IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602016
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-2016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1679 E MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5212
Practice Address - Country:US
Practice Address - Phone:619-441-1907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-17
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF79975106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist