Provider Demographics
NPI:1720322662
Name:VELASCO, MAYRA
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:VELASCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:E. ST. LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-0204
Mailing Address - Country:US
Mailing Address - Phone:618-213-3170
Mailing Address - Fax:618-213-3171
Practice Address - Street 1:5601 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62203-1346
Practice Address - Country:US
Practice Address - Phone:618-213-3170
Practice Address - Fax:618-213-3171
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$OtherDHS