Provider Demographics
NPI:1962779108
Name:VALLEJOS, GUILLERMO I (PT)
Entity type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:I
Last Name:VALLEJOS
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E 2ND AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-1718
Mailing Address - Country:US
Mailing Address - Phone:321-521-1161
Mailing Address - Fax:321-521-1161
Practice Address - Street 1:220 N SYKES CREEK PKWY STE 201
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3490
Practice Address - Country:US
Practice Address - Phone:321-521-1161
Practice Address - Fax:321-521-1161
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2534225100000X
FLPT31117225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist