Provider Demographics
NPI:1336737113
Name:VELAZQUEZ, ELIZABETH NA
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:NA
Last Name:VELAZQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:NA
Other - Last Name:IXTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:49211 GRAPEFRUIT BLVD STE 5&6
Mailing Address - Street 2:
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236-1480
Mailing Address - Country:US
Mailing Address - Phone:760-541-8520
Mailing Address - Fax:
Practice Address - Street 1:49211 GRAPEFRUIT BLVD STE 5&6
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-1480
Practice Address - Country:US
Practice Address - Phone:760-541-8520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC8837101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health