Provider Demographics
NPI:1710593066
Name:VELARDE, SAMUEL RAY
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:RAY
Last Name:VELARDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 SWEETBRIAR DR APT 716
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6738
Mailing Address - Country:US
Mailing Address - Phone:325-812-6041
Mailing Address - Fax:
Practice Address - Street 1:439 W HARRIS AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6392
Practice Address - Country:US
Practice Address - Phone:325-939-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician