=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578703609
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PENELOPE VELAZQUEZ MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2009
-----------------------------------------------------
Last Update Date | 03/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2755 JEFFERSON ST
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-529-9205
-----------------------------------------------------
Fax | 760-721-1862
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1784 TROY LN
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92054-5648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-722-0908
-----------------------------------------------------
Fax | 760-721-1862
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MFT 18814
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------