Provider Demographics
NPI:1275114738
Name:VELAZQUEZ, PATRICK MYLES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:MYLES
Last Name:VELAZQUEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3707
Mailing Address - Country:US
Mailing Address - Phone:318-572-1919
Mailing Address - Fax:
Practice Address - Street 1:1222 S PATTERSON BLVD STE 230
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2643
Practice Address - Country:US
Practice Address - Phone:318-572-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.22035871041C0700X
LA128471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical