Healthcare Provider Details

I. General information

NPI: 1265097794
Provider Name (Legal Business Name): MISAEL ELY VELAZQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 N R ST STE 101
MADERA CA
93637-4465
US

IV. Provider business mailing address

PO BOX 1288
MADERA CA
93639-1288
US

V. Phone/Fax

Practice location:
  • Phone: 559-662-0527
  • Fax:
Mailing address:
  • Phone: 559-598-2983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT144128
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: