Healthcare Provider Details

I. General information

NPI: 1043898471
Provider Name (Legal Business Name): MADISON ELAINE VELASQUEZ-WALSH-SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19712 MACARTHUR BLVD STE 110
IRVINE CA
92612-2407
US

IV. Provider business mailing address

PO BOX 4291
COSTA MESA CA
92628-4291
US

V. Phone/Fax

Practice location:
  • Phone: 714-725-9897
  • Fax:
Mailing address:
  • Phone: 949-436-8538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: