Provider Demographics
NPI:1437410834
Name:MORTEMORE, JUSTIN A (HAS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:A
Last Name:MORTEMORE
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8006 IVYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-4212
Mailing Address - Country:US
Mailing Address - Phone:419-376-9860
Mailing Address - Fax:
Practice Address - Street 1:8006 IVYWOOD LN
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560
Practice Address - Country:US
Practice Address - Phone:419-376-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03000237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist