Provider Demographics
NPI:1659473361
Name:MORTENSEN, BARTLEY BRETT (PT)
Entity Type:Individual
Prefix:
First Name:BARTLEY
Middle Name:BRETT
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-429-8000
Mailing Address - Fax:801-429-8150
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:SUITE 122
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-429-0610
Practice Address - Fax:801-429-0629
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT51321992401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT827322OtherDMBA
UT219420OtherALTIUS
UT64-00662OtherUNITED HEALTHCARE
UT76205OtherPEHP
UTP00146137OtherPALMETTO
UT870281028000Medicaid
UTP00146137OtherPALMETTO
UT219420OtherALTIUS
UT870281028000Medicaid
UT005502546Medicare PIN