Provider Demographics
NPI:1336508159
Name:MORTENSEN, MCKENZIE (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 SILAS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3013
Mailing Address - Country:US
Mailing Address - Phone:336-713-7436
Mailing Address - Fax:
Practice Address - Street 1:700 LEONA DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3429
Practice Address - Country:US
Practice Address - Phone:602-677-7183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11840225X00000X
AZ6475225X00000X
MI5201012978225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist