=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467676247
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CYRIL TOWNSEND VELKOFF M.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2007
-----------------------------------------------------
Last Update Date | 02/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 EAST ST
-----------------------------------------------------
City | WILLIAMSPORT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17701-6613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-337-3320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 830 FOGELMAN RD
-----------------------------------------------------
City | MUNCY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17756-6811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-337-3320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PS005208L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PS005208L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------