Provider Demographics
NPI:1992472542
Name:LOPEZ-VELAZQUEZ, VANESSA MICHELLE
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:MICHELLE
Last Name:LOPEZ-VELAZQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:MICHELLE
Other - Last Name:LOPEZ IRIARTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 WILSHIRE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1931
Mailing Address - Country:US
Mailing Address - Phone:213-481-7464
Mailing Address - Fax:
Practice Address - Street 1:1200 WILSHIRE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1931
Practice Address - Country:US
Practice Address - Phone:213-481-7464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAAPPC11859101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program