Provider Demographics
NPI:1962017517
Name:ORTA-GONZALES, ARELLY VANESSA (LMT, MTI)
Entity type:Individual
Prefix:
First Name:ARELLY
Middle Name:VANESSA
Last Name:ORTA-GONZALES
Suffix:
Gender:F
Credentials:LMT, MTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 JACKSBORO HWY STE 402
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76114-1600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5501 JACKSBORO HWY STE 402
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-1600
Practice Address - Country:US
Practice Address - Phone:817-226-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109705225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist