Provider Demographics
NPI:1619650389
Name:MORTENSEN, CLARA KATE (SLP-CCC)
Entity Type:Individual
Prefix:MRS
First Name:CLARA
Middle Name:KATE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 OLD MAIN HL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-6810
Mailing Address - Country:US
Mailing Address - Phone:435-797-3727
Mailing Address - Fax:
Practice Address - Street 1:6810 OLD MAIN HL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-6810
Practice Address - Country:US
Practice Address - Phone:435-797-3727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12881978-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist