Provider Demographics
NPI:1801541966
Name:VELASQUEZ, SHAWANA VICTORIA
Entity type:Individual
Prefix:
First Name:SHAWANA
Middle Name:VICTORIA
Last Name:VELASQUEZ
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 1:820 E AVENUE J12
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4185
Mailing Address - Country:US
Mailing Address - Phone:661-236-2984
Mailing Address - Fax:
Practice Address - Street 1:23502 LYONS AVE STE 304A
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91321-2538
Practice Address - Country:US
Practice Address - Phone:661-702-0166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician