Provider Demographics
NPI:1952881062
Name:MANRIQUEZ, BLANCA IVETTE (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:BLANCA
Middle Name:IVETTE
Last Name:MANRIQUEZ
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MRS
Other - First Name:BLANCA
Other - Middle Name:IVETTE
Other - Last Name:MANRIQUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:3625 CLUBGATE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-2928
Mailing Address - Country:US
Mailing Address - Phone:915-373-8721
Mailing Address - Fax:
Practice Address - Street 1:4201 STONEGATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-9503
Practice Address - Country:US
Practice Address - Phone:817-924-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214069224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty