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NPI Code Detail

MEDICARE: MAYRA VELASCO

MEDICARE: MAYRA VELASCO
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
1101Y00000XCounselor

General Provider Information

NPI Number : 1720322662
Entity Type Code : Individual
Provider Name (Legal Business Name) : MAYRA VELASCO
Provider Business Mailing Address
First Line : 5601 STATE STREET
Second Line :
City : E. ST. LOUIS
State : IL
Zip : 62203-0204
Country : US
Telephone Number : 618-213-3170
Fax Number : 618-213-3171
Provider Business Practice Location Address
First Line : 5601 STATE ST
Second Line :
City : EAST SAINT LOUIS
State : IL
Zip : 62203-1346
Country : US
Telephone Number : 618-213-3170
Fax Number : 618-213-3171
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/15/2012
Last Update Date : 11/15/2012

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Directions to “ MAYRA VELASCO ” Practice Location

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