Provider Demographics
NPI:1295039345
Name:MORTENSEN, LISA ANN (MPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26314 PRESIDIO BLF
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78015-6560
Mailing Address - Country:US
Mailing Address - Phone:210-954-2806
Mailing Address - Fax:
Practice Address - Street 1:26314 PRESIDIO BLF
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78015-6560
Practice Address - Country:US
Practice Address - Phone:210-954-2806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1192920225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist