Healthcare Provider Details

I. General information

NPI: 1861791436
Provider Name (Legal Business Name): EDNA NAZARIO-VELASCO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CALLE TANCA SUITE 3-D
SAN JUAN PR
00901-1933
US

IV. Provider business mailing address

300 CALLE TANCA SUITE 3-D
SAN JUAN PR
00901-1933
US

V. Phone/Fax

Practice location:
  • Phone: 787-977-6885
  • Fax:
Mailing address:
  • Phone: 787-977-6885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number460
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number460
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: