Provider Demographics
NPI:1740046846
Name:VELASQUEZ, LUIS ANTONIO (SOCIAL WORKER)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ANTONIO
Last Name:VELASQUEZ
Suffix:
Gender:M
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22465 DUFFY RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1766
Mailing Address - Country:US
Mailing Address - Phone:315-767-1649
Mailing Address - Fax:
Practice Address - Street 1:11050 MT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-2603
Practice Address - Country:US
Practice Address - Phone:315-772-9519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119408-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical