Provider Demographics
NPI:1366781254
Name:VELAZQUEZ, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:VELAZQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:OWCZARCZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:240 MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-4031
Mailing Address - Country:US
Mailing Address - Phone:716-830-7080
Mailing Address - Fax:
Practice Address - Street 1:240 MOORE AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-4031
Practice Address - Country:US
Practice Address - Phone:716-830-7080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019207-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03756094Medicaid