Provider Demographics
NPI:1598818726
Name:MORTENSEN, ELLEN B (MSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:B
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16376 28TH PL NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-6417
Mailing Address - Country:US
Mailing Address - Phone:206-459-3556
Mailing Address - Fax:
Practice Address - Street 1:16376 28TH PL NE
Practice Address - Street 2:SHORELINE
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-6417
Practice Address - Country:US
Practice Address - Phone:206-459-3556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00004069104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8356966Medicaid
WAGAB34459Medicare PIN
WA8356966Medicaid