Provider Demographics
NPI:1275031197
Name:VELAZQUEZ AZCANO, NIDIA RUTH
Entity Type:Individual
Prefix:
First Name:NIDIA
Middle Name:RUTH
Last Name:VELAZQUEZ AZCANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15308 SW 72ND ST # 26-13
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1631
Mailing Address - Country:US
Mailing Address - Phone:239-692-0175
Mailing Address - Fax:305-232-6809
Practice Address - Street 1:15308 SW 72ND ST # 26-13
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-1631
Practice Address - Country:US
Practice Address - Phone:239-692-0175
Practice Address - Fax:305-232-6809
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician