Provider Demographics
NPI:1508191677
Name:MORTENSEN, ARVID LELAND (LICSW)
Entity Type:Individual
Prefix:
First Name:ARVID
Middle Name:LELAND
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MARKET ST
Mailing Address - Street 2:SUITE 4A
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-5532
Mailing Address - Country:US
Mailing Address - Phone:507-452-5033
Mailing Address - Fax:507-452-5183
Practice Address - Street 1:111 MARKET ST
Practice Address - Street 2:SUITE 4A
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-5532
Practice Address - Country:US
Practice Address - Phone:507-452-5033
Practice Address - Fax:507-452-5183
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN85881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical