Provider Demographics
NPI:1275268757
Name:MORTNER, EMILY VIOLET
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:VIOLET
Last Name:MORTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 N WINOOSKI AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-3748
Mailing Address - Country:US
Mailing Address - Phone:203-644-7632
Mailing Address - Fax:
Practice Address - Street 1:90 N WINOOSKI AVE APT 4
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3748
Practice Address - Country:US
Practice Address - Phone:203-644-7632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT144.0134219235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist