Provider Demographics
NPI:1710629803
Name:MORTENSEN, AMBER LEE (LMT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LEE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 REGENCY RD STE 103
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2333
Mailing Address - Country:US
Mailing Address - Phone:859-420-4577
Mailing Address - Fax:
Practice Address - Street 1:2035 REGENCY RD STE 103
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2333
Practice Address - Country:US
Practice Address - Phone:859-420-4577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-10
Last Update Date:2022-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252820225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist