Provider Demographics
NPI:1043406903
Name:ORTALEZA, MA. ESTELA LOPEZ (PT)
Entity Type:Individual
Prefix:
First Name:MA. ESTELA
Middle Name:LOPEZ
Last Name:ORTALEZA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 S JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-2524
Mailing Address - Country:US
Mailing Address - Phone:417-624-2061
Mailing Address - Fax:
Practice Address - Street 1:2700 E 34TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4310
Practice Address - Country:US
Practice Address - Phone:417-781-1737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2015-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007018572225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist