Provider Demographics
NPI:1740797828
Name:VELASCO, ROY H JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:H
Last Name:VELASCO
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MISSOURI CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-6450
Mailing Address - Country:US
Mailing Address - Phone:301-305-2963
Mailing Address - Fax:
Practice Address - Street 1:8701 GEORGIA AVE STE LL1
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3722
Practice Address - Country:US
Practice Address - Phone:301-587-5333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4162225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty