Provider Demographics
NPI:1477982908
Name:VELASCO, MAE ODSEY (PT)
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:ODSEY
Last Name:VELASCO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4471
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-4471
Mailing Address - Country:US
Mailing Address - Phone:910-695-5851
Mailing Address - Fax:
Practice Address - Street 1:300 BLAKE BLVD
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8474
Practice Address - Country:US
Practice Address - Phone:910-295-6158
Practice Address - Fax:910-295-1438
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP11472225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist