Provider Demographics
NPI:1891872479
Name:VELAZQUEZ, MARIANO ENRIQUE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARIANO
Middle Name:ENRIQUE
Last Name:VELAZQUEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8622 MARJORAM DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825
Mailing Address - Country:US
Mailing Address - Phone:407-275-7625
Mailing Address - Fax:
Practice Address - Street 1:2101 PARK CENTER DRIVE
Practice Address - Street 2:SUITE 270
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835
Practice Address - Country:US
Practice Address - Phone:407-523-1213
Practice Address - Fax:407-523-2398
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ3888AMedicare ID - Type Unspecified