Provider Demographics
NPI:1376927541
Name:MORTENSEN, GREGGORY (DPT)
Entity Type:Individual
Prefix:
First Name:GREGGORY
Middle Name:
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7701 NE HIGHWAY 99 STE 109
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8871
Mailing Address - Country:US
Mailing Address - Phone:360-605-0416
Mailing Address - Fax:360-605-0417
Practice Address - Street 1:7701 NE HIGHWAY 99 STE 109
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8871
Practice Address - Country:US
Practice Address - Phone:360-605-0416
Practice Address - Fax:360-605-0417
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT61158225100000X
WA60735053225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG9012098Medicaid
WAAB39793Medicaid