Provider Demographics
NPI:1295301372
Name:VELEZ, KRISTIN WICELLY (CBT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:WICELLY
Last Name:VELEZ
Suffix:
Gender:F
Credentials:CBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1284 NE MOUNT OLYMPUS LN APT D105
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-3898
Mailing Address - Country:US
Mailing Address - Phone:407-499-5488
Mailing Address - Fax:
Practice Address - Street 1:1284 NE MOUNT OLYMPUS LN APT D105
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-3898
Practice Address - Country:US
Practice Address - Phone:407-499-5488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA016457562-01Medicaid