Provider Demographics
NPI:1194842021
Name:VELASQUEZ, BENITO (ATC LAT)
Entity Type:Individual
Prefix:
First Name:BENITO
Middle Name:
Last Name:VELASQUEZ
Suffix:
Gender:M
Credentials:ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 TAFT BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2099
Mailing Address - Country:US
Mailing Address - Phone:940-397-4829
Mailing Address - Fax:940-397-4901
Practice Address - Street 1:118 COLLEGE DR # 5142
Practice Address - Street 2:UNIVERSITY OF SOUTHERN MISSISSIPPI
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39406-0001
Practice Address - Country:US
Practice Address - Phone:601-266-6058
Practice Address - Fax:601-266-4445
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT 01132255A2300X
TXAT49142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer