Healthcare Provider Details

I. General information

NPI: 1780082016
Provider Name (Legal Business Name): CHARLES VELEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2014
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6110 SHALLOWFORD RD
CHATTANOOGA TN
37421-1894
US

IV. Provider business mailing address

4053 PEERLESS RD NW
CLEVELAND TN
37312-3445
US

V. Phone/Fax

Practice location:
  • Phone: 888-291-4357
  • Fax: 423-296-6384
Mailing address:
  • Phone: 423-883-0308
  • Fax: 423-296-6384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: