Provider Demographics
NPI:1780468041
Name:VELASQUEZ, TANYA ANN (SUD)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:ANN
Last Name:VELASQUEZ
Suffix:
Gender:F
Credentials:SUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 OSBUN RD UNIT 12
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4631
Mailing Address - Country:US
Mailing Address - Phone:909-695-2055
Mailing Address - Fax:
Practice Address - Street 1:265 S ANITA DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3355
Practice Address - Country:US
Practice Address - Phone:949-749-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-18
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16215101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)