Provider Demographics
NPI:1467096917
Name:RUSSELL MORTENSEN, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:RUSSELL MORTENSEN
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 1:1124 E 1100 S
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-1316
Mailing Address - Country:US
Mailing Address - Phone:801-644-0726
Mailing Address - Fax:
Practice Address - Street 1:1422 E 820 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-5481
Practice Address - Country:US
Practice Address - Phone:801-644-0726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11151552-3902106H00000X
UT11151552-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist