Provider Demographics
NPI:1548750508
Name:MORTENSEN, BRYCE
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 W CLEARWATER AVE STE B101
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1694
Mailing Address - Country:US
Mailing Address - Phone:509-544-0265
Mailing Address - Fax:509-987-1614
Practice Address - Street 1:252 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-1840
Practice Address - Country:US
Practice Address - Phone:541-701-0708
Practice Address - Fax:541-701-0710
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist