Provider Demographics
NPI:1467186270
Name:MORTENSON, HALEY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5699 BRIARDALE CT APT B
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-5248
Mailing Address - Country:US
Mailing Address - Phone:650-391-8654
Mailing Address - Fax:
Practice Address - Street 1:210 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-1115
Practice Address - Country:US
Practice Address - Phone:740-845-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT019680225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist