Healthcare Provider Details

I. General information

NPI: 1093684201
Provider Name (Legal Business Name): CAMILY VELASQUEZ DE VEGA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2025
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 S MILLER ST STE 5
SANTA MARIA CA
93454-6961
US

IV. Provider business mailing address

1104 N 3RD ST
LOMPOC CA
93436-3633
US

V. Phone/Fax

Practice location:
  • Phone: 805-460-3623
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: