Provider Demographics
NPI:1760851877
Name:VELEZ, ERIC SANTIAGO (CSW)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:SANTIAGO
Last Name:VELEZ
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 FAIRWAY ST STE 103
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-2452
Mailing Address - Country:US
Mailing Address - Phone:270-904-6302
Mailing Address - Fax:270-904-6314
Practice Address - Street 1:1143 FAIRWAY ST STE 103
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-2452
Practice Address - Country:US
Practice Address - Phone:270-904-6302
Practice Address - Fax:270-904-6314
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7455104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker