Provider Demographics
NPI:1336924521
Name:FORTIZ, BAYLEIGH NICKOLE (OT)
Entity Type:Individual
Prefix:
First Name:BAYLEIGH
Middle Name:NICKOLE
Last Name:FORTIZ
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 226656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75222-6656
Mailing Address - Country:US
Mailing Address - Phone:214-943-9431
Mailing Address - Fax:214-943-9431
Practice Address - Street 1:1102 SOLON PLACE WAY STE 2
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-5038
Practice Address - Country:US
Practice Address - Phone:972-875-7488
Practice Address - Fax:972-875-7508
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
123870225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty