Healthcare Provider Details

I. General information

NPI: 1730036625
Provider Name (Legal Business Name): CITLALLI MICHELLE AGUILAR VELAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2026
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 BOREL AVE STE 101
SAN MATEO CA
94402-3525
US

IV. Provider business mailing address

6248 3RD ST
SAN FRANCISCO CA
94124-3110
US

V. Phone/Fax

Practice location:
  • Phone: 408-641-3187
  • Fax:
Mailing address:
  • Phone: 415-601-0264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: