Provider Demographics
NPI:1851839609
Name:VELASQUEZ, ADELINA
Entity Type:Individual
Prefix:
First Name:ADELINA
Middle Name:
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 1:23361 EL TORO RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6922
Mailing Address - Country:US
Mailing Address - Phone:949-595-0620
Mailing Address - Fax:949-565-0240
Practice Address - Street 1:23361 EL TORO ROAD
Practice Address - Street 2:SUITE 215
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-6921
Practice Address - Country:US
Practice Address - Phone:949-595-0602
Practice Address - Fax:949-565-0240
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78199106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist