Provider Demographics
NPI:1548711583
Name:GOODWELL-VELEZ, LAURA YASUKO (ATC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:YASUKO
Last Name:GOODWELL-VELEZ
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:YASUKO
Other - Last Name:GOODWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:2621 GLENROSE AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-5031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5719 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1985
Practice Address - Country:US
Practice Address - Phone:315-883-5886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003202-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer