Provider Demographics
NPI:1235622838
Name:VELASCO, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VELASCO
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 1:13668 KINGS CANYON CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-3806
Mailing Address - Country:US
Mailing Address - Phone:626-371-6635
Mailing Address - Fax:626-371-6635
Practice Address - Street 1:13668 KINGS CANYON CT
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3806
Practice Address - Country:US
Practice Address - Phone:626-371-6635
Practice Address - Fax:626-371-6635
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician