Provider Demographics
NPI:1811731722
Name:GUTIERREZ VELAZQUEZ, JUAN EDUARDO (LPTA)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:EDUARDO
Last Name:GUTIERREZ VELAZQUEZ
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 ORANGE LEAF CT
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-7673
Mailing Address - Country:US
Mailing Address - Phone:540-449-3709
Mailing Address - Fax:
Practice Address - Street 1:206 6TH ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-2408
Practice Address - Country:US
Practice Address - Phone:540-633-1003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306606414225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant