Provider Demographics
NPI:1316466303
Name:ORTIZ, MALLORY MASSEY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:MASSEY
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18565 KOCUREK RD
Mailing Address - Street 2:
Mailing Address - City:GUY
Mailing Address - State:TX
Mailing Address - Zip Code:77444-9501
Mailing Address - Country:US
Mailing Address - Phone:979-864-6104
Mailing Address - Fax:
Practice Address - Street 1:3205 JENNY LIND RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-7101
Practice Address - Country:US
Practice Address - Phone:479-709-6092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1518089556Medicaid