Healthcare Provider Details

I. General information

NPI: 1659498921
Provider Name (Legal Business Name): RUBY VELASCO MFT-I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 HURLBUT ST
PASADENA CA
91105-4025
US

IV. Provider business mailing address

320 N STONEMAN AVE
ALHAMBRA CA
91801-2411
US

V. Phone/Fax

Practice location:
  • Phone: 626-441-4221
  • Fax: 626-441-6479
Mailing address:
  • Phone: 626-484-0744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number51483
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: