=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508528522
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. EVA VELEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2021
-----------------------------------------------------
Last Update Date | 10/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 S LIBERTY DR STE A
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47403-5147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-727-6701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4331 N STATE ROAD 59
-----------------------------------------------------
City | LINTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47441-6231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-848-9101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------