Healthcare Provider Details

I. General information

NPI: 1508770876
Provider Name (Legal Business Name): MAYRA VELASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 PACIFIC BLVD
HUNTINGTON PARK CA
90255-2618
US

IV. Provider business mailing address

4425 W 102ND ST # T
INGLEWOOD CA
90304-1533
US

V. Phone/Fax

Practice location:
  • Phone: 661-360-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: