Provider Demographics
NPI:1861791436
Name:NAZARIO-VELASCO, EDNA (PHD)
Entity type:Individual
Prefix:DR
First Name:EDNA
Middle Name:
Last Name:NAZARIO-VELASCO
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 1:300 CALLE TANCA
Mailing Address - Street 2:SUITE 3-D
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00901-1933
Mailing Address - Country:US
Mailing Address - Phone:787-977-6885
Mailing Address - Fax:
Practice Address - Street 1:300 CALLE TANCA
Practice Address - Street 2:SUITE 3-D
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00901-1933
Practice Address - Country:US
Practice Address - Phone:787-977-6885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR460103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent