Provider Demographics
NPI:1598777245
Name:MORTENSEN, ALEISHA MARIE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:ALEISHA
Middle Name:MARIE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:OTRL
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 13507
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113
Mailing Address - Country:US
Mailing Address - Phone:501-570-4004
Mailing Address - Fax:501-570-4003
Practice Address - Street 1:6917 GEYER SPRINGS ROAD
Practice Address - Street 2:SUITE 1 S
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209
Practice Address - Country:US
Practice Address - Phone:501-570-4004
Practice Address - Fax:501-570-4003
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1775225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X015OtherBLUE CROSS BLUE SHIELD