Healthcare Provider Details

I. General information

NPI: 1396342937
Provider Name (Legal Business Name): DENISE VELAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 03/29/2025
Certification Date: 03/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 E GILBERT ST BLDG H
SAN BERNARDINO CA
92415-5085
US

IV. Provider business mailing address

1970 7TH ST APT 115
RIVERSIDE CA
92507-4391
US

V. Phone/Fax

Practice location:
  • Phone: 909-763-4760
  • Fax:
Mailing address:
  • Phone: 323-831-4867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number17881
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberY3758975
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: