Healthcare Provider Details

I. General information

NPI: 1013138239
Provider Name (Legal Business Name): DR. MATTHEW MICHAEL VELASQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MATTHEW MICHAEL VELASQUEZ PH.D.

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20710 LEAPWOOD AVE STE. C
CARSON CA
90746-3642
US

IV. Provider business mailing address

25400 OAK ST APT. #4
LOMITA CA
90717-2262
US

V. Phone/Fax

Practice location:
  • Phone: 310-324-0447
  • Fax: 310-324-0147
Mailing address:
  • Phone: 310-766-7931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: