Healthcare Provider Details

I. General information

NPI: 1902786106
Provider Name (Legal Business Name): DOMINIQUE ALLYSSA VELAZQUEZ PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6710 MALLERY DR
LANHAM MD
20706-3964
US

IV. Provider business mailing address

18881 W DODGE RD STE 300W
ELKHORN NE
68022-4648
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17561-24
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.029410
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: