Provider Demographics
NPI:1912941436
Name:VELASQUEZ, JOSE ROBERTO (CASE MANAGER)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ROBERTO
Last Name:VELASQUEZ
Suffix:
Gender:M
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 CALLE DE ALEGRA STE A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:826 ANTHONY DR
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021
Practice Address - Country:US
Practice Address - Phone:575-201-5135
Practice Address - Fax:575-449-4052
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA596318Medicare UPIN
CACP13120CMedicare ID - Type Unspecified