Provider Demographics
NPI:1023562881
Name:MORTENSON, WILLISTON (DPT)
Entity Type:Individual
Prefix:
First Name:WILLISTON
Middle Name:
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 WILLIAMS ST
Mailing Address - Street 2:STE 1
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-7463
Mailing Address - Country:US
Mailing Address - Phone:413-447-8070
Mailing Address - Fax:413-445-4918
Practice Address - Street 1:740 WILLIAMS ST
Practice Address - Street 2:STE 1
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-7463
Practice Address - Country:US
Practice Address - Phone:413-447-8070
Practice Address - Fax:413-445-4918
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22469225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist