Provider Demographics
NPI:1396970901
Name:LEON-VELAZQUEZ, MARIELA (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIELA
Middle Name:
Last Name:LEON-VELAZQUEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:DBA/PSYCHE,
Other - Middle Name:
Other - Last Name:SERVICIOS PSICOLOGICOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8133 CALLE MARTIN CORCHADO
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-1123
Mailing Address - Country:US
Mailing Address - Phone:787-515-9770
Mailing Address - Fax:787-259-9040
Practice Address - Street 1:8133 CALLE MARTIN CORCHADO
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1123
Practice Address - Country:US
Practice Address - Phone:787-515-9770
Practice Address - Fax:787-259-9040
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3250103TC0700X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical