Healthcare Provider Details

I. General information

NPI: 1376248880
Provider Name (Legal Business Name): KAREN MARIELA VELASQUEZ POLANCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 N HANDY ST
ORANGE CA
92867-4434
US

IV. Provider business mailing address

1513 ROSE AVE
LONG BEACH CA
90813-2531
US

V. Phone/Fax

Practice location:
  • Phone: 714-628-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number973AF27BBC
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: