Provider Demographics
NPI:1477710002
Name:DICK, EVELYN VELASCO (LMT)
Entity Type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:VELASCO
Last Name:DICK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4641 WADITA KA WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33417-8016
Mailing Address - Country:US
Mailing Address - Phone:561-308-6639
Mailing Address - Fax:
Practice Address - Street 1:3944 FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-2271
Practice Address - Country:US
Practice Address - Phone:561-308-6639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42083174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist