Provider Demographics
NPI:1659973287
Name:VELAZQUEZ, NOEL JESUS
Entity Type:Individual
Prefix:
First Name:NOEL
Middle Name:JESUS
Last Name:VELAZQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8858 S 55TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-1284
Mailing Address - Country:US
Mailing Address - Phone:708-646-8886
Mailing Address - Fax:
Practice Address - Street 1:3253 S HARLEM AVE STE 1B
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-5496
Practice Address - Country:US
Practice Address - Phone:708-788-3880
Practice Address - Fax:708-788-4757
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.025520225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070.025520OtherSTATE LICENSE