Provider Demographics
NPI:1831889161
Name:VELASCO, ENID A
Entity type:Individual
Prefix:
First Name:ENID
Middle Name:A
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:PO BOX 3602
Mailing Address - Street 2:
Mailing Address - City:RUNNING SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92382-3602
Mailing Address - Country:US
Mailing Address - Phone:909-496-1233
Mailing Address - Fax:
Practice Address - Street 1:30616 S FERNDALE DR.
Practice Address - Street 2:
Practice Address - City:RUNNING SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92382-3602
Practice Address - Country:US
Practice Address - Phone:909-496-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical