Healthcare Provider Details

I. General information

NPI: 1366077653
Provider Name (Legal Business Name): GENNICA ASHLEY VELASCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 FORD ST
OAKLAND CA
94601-2114
US

IV. Provider business mailing address

2828 FORD ST
OAKLAND CA
94601-2114
US

V. Phone/Fax

Practice location:
  • Phone: 510-871-1909
  • Fax:
Mailing address:
  • Phone: 510-871-1909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number149038
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: