Healthcare Provider Details

I. General information

NPI: 1578065801
Provider Name (Legal Business Name): VANESSA MARIE VELASCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 CRENSHAW BLVD STE 215
LOS ANGELES CA
90043-1200
US

IV. Provider business mailing address

4401 CRENSHAW BLVD STE 215
LOS ANGELES CA
90043-1200
US

V. Phone/Fax

Practice location:
  • Phone: 323-291-7100
  • Fax:
Mailing address:
  • Phone: 323-291-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-48611
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: