Provider Demographics
NPI:1669652103
Name:VELASQUEZ, AVA LEIGH
Entity Type:Individual
Prefix:
First Name:AVA
Middle Name:LEIGH
Last Name:VELASQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NE LOOP 820
Mailing Address - Street 2:200
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-7209
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:
Practice Address - Street 1:17480 DALLAS PKWY
Practice Address - Street 2:STE. 221
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-7337
Practice Address - Country:US
Practice Address - Phone:817-292-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116193225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics