=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396970901
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIELA LEON-VELAZQUEZ PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2009
-----------------------------------------------------
Last Update Date | 03/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8133 CALLE MARTIN CORCHADO
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00717-1123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-515-9770
-----------------------------------------------------
Fax | 787-259-9040
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8133 CALLE MARTIN CORCHADO
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00717-1123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-515-9770
-----------------------------------------------------
Fax | 787-259-9040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 3250
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------