Provider Demographics
NPI:1467732172
Name:MORTENSON, MELODY M (LCSW)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:M
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-0555
Mailing Address - Country:US
Mailing Address - Phone:479-879-2115
Mailing Address - Fax:
Practice Address - Street 1:4241 N GABEL DR STE 2B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5296
Practice Address - Country:US
Practice Address - Phone:479-879-2115
Practice Address - Fax:479-249-6989
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2551-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical