Provider Demographics
NPI:1255412573
Name:VELASQUEZ, MAGDALENA OLIVIA (MFT)
Entity type:Individual
Prefix:
First Name:MAGDALENA
Middle Name:OLIVIA
Last Name:VELASQUEZ
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 SEAVIEW ST
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3188 AIRWAY AVE
Practice Address - Street 2:UNIT F
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4652
Practice Address - Country:US
Practice Address - Phone:714-788-0573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 42136106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist