Provider Demographics
NPI:1194814269
Name:MORTELL, COLLEEN MARY (PHD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARY
Last Name:MORTELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 MARSHALL CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2255
Mailing Address - Country:US
Mailing Address - Phone:608-238-9354
Mailing Address - Fax:608-238-7675
Practice Address - Street 1:2727 MARSHALL CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2255
Practice Address - Country:US
Practice Address - Phone:608-238-9354
Practice Address - Fax:608-238-7675
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2035103T00000X
WI2035-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39712000Medicaid