Provider Demographics
NPI:1821583378
Name:VELAZQUEZ, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:VELAZQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:MENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:815 COLORADO BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1744
Mailing Address - Country:US
Mailing Address - Phone:323-543-2800
Mailing Address - Fax:323-978-1263
Practice Address - Street 1:13001 RAMONA BLVD STE A
Practice Address - Street 2:
Practice Address - City:IRWINDALE
Practice Address - State:CA
Practice Address - Zip Code:91706-3752
Practice Address - Country:US
Practice Address - Phone:626-373-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CA1001501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171M00000XOtherLADMH