MEDICARE: NATHAN VELEZ PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	LAC12953	AZ
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	LASAC13129	AZ
3	101YP2500X	Professional Counselor	LPC14297	AZ

General Provider Information

NPI Number	:	1104076512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN VELEZ PH.D

Provider Business Mailing Address
First Line	:	105 N 5TH AVE
Second Line	:
City	:	HOLBROOK
State	:	AZ
Zip	:	86025-2817
Country	:	US
Telephone Number	:	928-524-6701
Fax Number	:	928-524-3086

Provider Business Practice Location Address
First Line	:	105 N 5TH AVE
Second Line	:
City	:	HOLBROOK
State	:	AZ
Zip	:	86025-2817
Country	:	US
Telephone Number	:	928-524-6126
Fax Number	:	928-524-6090

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2008
Last Update Date	:	07/19/2013

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