Provider Demographics
NPI:1194490623
Name:VELASCO, VANESSA (CDA)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:VELASCO
Suffix:
Gender:F
Credentials:CDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13614 THUNDERBIRD PL
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-6857
Mailing Address - Country:US
Mailing Address - Phone:760-217-9056
Mailing Address - Fax:
Practice Address - Street 1:4688 ONTARIO MILLS PKWY
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5104
Practice Address - Country:US
Practice Address - Phone:909-923-3352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician