Provider Demographics
NPI:1730203860
Name:VELASQUEZ, PATTIJO N (PHD)
Entity type:Individual
Prefix:DR
First Name:PATTIJO
Middle Name:N
Last Name:VELASQUEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 S DON ROSER DR
Mailing Address - Street 2:STE. A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4596
Mailing Address - Country:US
Mailing Address - Phone:575-636-2506
Mailing Address - Fax:888-854-0782
Practice Address - Street 1:1505 S DON ROSER DR
Practice Address - Street 2:STE. A
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4596
Practice Address - Country:US
Practice Address - Phone:575-636-2506
Practice Address - Fax:888-854-0782
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0051C103TP0016X
NM1278103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002602042Medicaid