Provider Demographics
NPI:1487232492
Name:VELASQUEZ, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:VELASQUEZ
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 1:1401 SAN CLEMENTE AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-3423
Mailing Address - Country:US
Mailing Address - Phone:505-379-8755
Mailing Address - Fax:
Practice Address - Street 1:5800 MCLEOD RD NE STE D5800
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2454
Practice Address - Country:US
Practice Address - Phone:505-379-8755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-115961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical