Provider Demographics
NPI:1386379238
Name:VELARDE, RAECHEL LAEL
Entity type:Individual
Prefix:
First Name:RAECHEL
Middle Name:LAEL
Last Name:VELARDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11516 GRAPE ST # 74
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-2214
Mailing Address - Country:US
Mailing Address - Phone:424-229-4777
Mailing Address - Fax:
Practice Address - Street 1:12021 WILMINGTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3019
Practice Address - Country:US
Practice Address - Phone:424-454-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAMPSS-PIGWCV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker