Provider Demographics
NPI:1598240517
Name:MORTENSEN, EMILY SUZANNE (LCPC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:SUZANNE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:SUZANNE
Other - Last Name:HOWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2596 N STOKESBERRY PL STE 170
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6115
Mailing Address - Country:US
Mailing Address - Phone:208-495-5434
Mailing Address - Fax:208-563-2602
Practice Address - Street 1:2596 N STOKESBERRY PL STE 170
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6115
Practice Address - Country:US
Practice Address - Phone:208-495-5434
Practice Address - Fax:208-563-2602
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-8457101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional