Provider Demographics
NPI:1265097794
Name:VELAZQUEZ, MISAEL ELY
Entity type:Individual
Prefix:
First Name:MISAEL
Middle Name:ELY
Last Name:VELAZQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1288
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93639-1288
Mailing Address - Country:US
Mailing Address - Phone:559-598-2983
Mailing Address - Fax:
Practice Address - Street 1:117 N R ST STE 101
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-4465
Practice Address - Country:US
Practice Address - Phone:559-662-0527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT144128106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist