Healthcare Provider Details

I. General information

NPI: 1487232492
Provider Name (Legal Business Name): MARIE VELASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 MCLEOD RD NE STE D5800
ALBUQUERQUE NM
87109-2454
US

IV. Provider business mailing address

1401 SAN CLEMENTE AVE NW
ALBUQUERQUE NM
87107-3423
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-8755
  • Fax:
Mailing address:
  • Phone: 505-379-8755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-11596
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: