Provider Demographics
NPI:1306411350
Name:ORTIZ PEREZ, MARIA MANUELA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:MANUELA
Last Name:ORTIZ PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7929 COLFAX LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76134-5028
Mailing Address - Country:US
Mailing Address - Phone:601-307-6674
Mailing Address - Fax:
Practice Address - Street 1:2825 VALLEY VIEW LN
Practice Address - Street 2:
Practice Address - City:FARMERS BRANCH
Practice Address - State:TX
Practice Address - Zip Code:75234-4955
Practice Address - Country:US
Practice Address - Phone:214-736-8376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-20-145078106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX465442672Medicaid