MEDICARE: KYISHA KIA VELAZQUEZ MA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1821599127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYISHA KIA VELAZQUEZ MA

Provider Business Mailing Address
First Line	:	408 NORTON PKWY
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-2829
Country	:	US
Telephone Number	:	203-903-8684
Fax Number	:

Provider Business Practice Location Address
First Line	:	446A BLAKE STREET
Second Line	:	SUITE 200
City	:	NEW HAVEN
State	:	CT
Zip	:	06515-0651
Country	:	US
Telephone Number	:	203-387-9400
Fax Number	:	203-387-9400

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2018
Last Update Date	:	02/22/2018

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