Healthcare Provider Details

I. General information

NPI: 1215855457
Provider Name (Legal Business Name): PAOLA BEATRIZ VELAZQUEZ- GONZALEZ DR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2514
US

IV. Provider business mailing address

113 LARKIN DR
MECHANICSBURG PA
17055-5238
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-2500
  • Fax:
Mailing address:
  • Phone: 787-241-6973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6301019869
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: