Provider Demographics
NPI:1295031631
Name:VELAZQUEZ, CARMEN S
Entity Type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:S
Last Name:VELAZQUEZ
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 1:1269 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-3614
Mailing Address - Country:US
Mailing Address - Phone:858-569-2111
Mailing Address - Fax:858-277-3948
Practice Address - Street 1:3002 ARMSTRONG ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-5702
Practice Address - Country:US
Practice Address - Phone:858-569-2116
Practice Address - Fax:858-277-3948
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59278106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist