Provider Demographics
NPI:1538514989
Name:VELASQUEZ, RAEGAN OWEN
Entity Type:Individual
Prefix:
First Name:RAEGAN
Middle Name:OWEN
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 1:129 S 700 E
Mailing Address - Street 2:APARTMENT 5
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-4237
Mailing Address - Country:US
Mailing Address - Phone:801-647-4255
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1700
Practice Address - Country:US
Practice Address - Phone:801-573-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101YA0400X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)