Provider Demographics
NPI:1013185602
Name:MORTENSON, SUZANNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:
Last Name:MORTENSON
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 1:123 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-1828
Mailing Address - Country:US
Mailing Address - Phone:801-766-8460
Mailing Address - Fax:801-766-9756
Practice Address - Street 1:123 N CENTER ST
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-1828
Practice Address - Country:US
Practice Address - Phone:801-766-8460
Practice Address - Fax:801-766-9756
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6561941-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist