Provider Demographics
NPI:1942812862
Name:VELASQUEZ, MIRANDA KERI (LCDC, LMFTA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:KERI
Last Name:VELASQUEZ
Suffix:
Gender:F
Credentials:LCDC, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1174 COUNTY ROAD 441
Mailing Address - Street 2:
Mailing Address - City:STOCKDALE
Mailing Address - State:TX
Mailing Address - Zip Code:78160-7028
Mailing Address - Country:US
Mailing Address - Phone:830-344-7396
Mailing Address - Fax:
Practice Address - Street 1:1174 COUNTY ROAD 441
Practice Address - Street 2:
Practice Address - City:STOCKDALE
Practice Address - State:TX
Practice Address - Zip Code:78160-7028
Practice Address - Country:US
Practice Address - Phone:830-344-7396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16215101YA0400X
171M00000X
TX204789106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator