MEDICARE: ARELLY VANESSA ORTA-GONZALES LMT, MTI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	109705	TX

General Provider Information

NPI Number	:	1962017517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ARELLY VANESSA ORTA-GONZALES LMT, MTI

Provider Business Mailing Address
First Line	:	5501 JACKSBORO HWY STE 402
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-1600
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5501 JACKSBORO HWY STE 402
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-1600
Country	:	US
Telephone Number	:	817-226-6551
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2020
Last Update Date	:	09/10/2020

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