Provider Demographics
NPI:1528651833
Name:MOTA VELAZCO, MINERVA MARIA
Entity type:Individual
Prefix:
First Name:MINERVA
Middle Name:MARIA
Last Name:MOTA VELAZCO
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 1:588 SANTIAGO AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-2427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:588 SANTIAGO AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-2427
Practice Address - Country:US
Practice Address - Phone:831-229-1194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77216225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty