Provider Demographics
NPI:1578180881
Name:VELILLA, LEIDY TATIANA (PT)
Entity type:Individual
Prefix:
First Name:LEIDY
Middle Name:TATIANA
Last Name:VELILLA
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 1:8635 QUEENS BLVD APT 2N
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4411
Mailing Address - Country:US
Mailing Address - Phone:929-471-8966
Mailing Address - Fax:
Practice Address - Street 1:8635 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4434
Practice Address - Country:US
Practice Address - Phone:929-471-8966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist