Provider Demographics
NPI:1629614052
Name:MORTISE, ROGER G (LPC)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:G
Last Name:MORTISE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5374 TWIN HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5682
Mailing Address - Country:US
Mailing Address - Phone:540-699-0226
Mailing Address - Fax:540-699-0224
Practice Address - Street 1:306 WESTWOOD OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5108
Practice Address - Country:US
Practice Address - Phone:540-699-0226
Practice Address - Fax:540-699-0224
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008698101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional