Provider Demographics
NPI:1194847863
Name:MORTENSON, DEAN STUART (MA,ADCT)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:STUART
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:MA,ADCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S MINNESOTA ST
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1601
Mailing Address - Country:US
Mailing Address - Phone:218-281-9436
Mailing Address - Fax:
Practice Address - Street 1:323 S MINNESOTA ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1601
Practice Address - Country:US
Practice Address - Phone:218-281-9436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302476101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)