Provider Demographics
NPI:1427774090
Name:VELASQUEZ, JUAN DAVID
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:DAVID
Last Name:VELASQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 W ADDISON ST APT 2S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4423
Mailing Address - Country:US
Mailing Address - Phone:630-772-0550
Mailing Address - Fax:
Practice Address - Street 1:3166 N LINCOLN AVE STE 310
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3119
Practice Address - Country:US
Practice Address - Phone:872-246-3903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health