Provider Demographics
NPI:1558433789
Name:VELASQUEZ, KATHLEEN (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:VELASQUEZ
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 1:111 WEATHERVANE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT ROYAL
Mailing Address - State:NJ
Mailing Address - Zip Code:08061-1051
Mailing Address - Country:US
Mailing Address - Phone:856-464-4662
Mailing Address - Fax:
Practice Address - Street 1:2716 ORTHODOX ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19137-1604
Practice Address - Country:US
Practice Address - Phone:215-743-4435
Practice Address - Fax:215-743-8848
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPT40QA00777700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist