Provider Demographics
NPI:1609052737
Name:VELASCO, EDWARD (MSW)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:VELASCO
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 GLEN AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1523
Mailing Address - Country:US
Mailing Address - Phone:323-296-1686
Mailing Address - Fax:
Practice Address - Street 1:9033 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-3839
Practice Address - Country:US
Practice Address - Phone:562-942-9625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAICAN789OtherDMH STAFF CODE