Provider Demographics
NPI:1578047999
Name:VELASCO, LAVINA (LCPC)
Entity Type:Individual
Prefix:
First Name:LAVINA
Middle Name:
Last Name:VELASCO
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W KIRBY AVE # 401
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-5507
Mailing Address - Country:US
Mailing Address - Phone:217-991-8309
Mailing Address - Fax:
Practice Address - Street 1:2516 WATERVILLE DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7416
Practice Address - Country:US
Practice Address - Phone:217-991-8309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP8399101YP2500X
IL180014477101YP2500X
MDLC11120101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional