Provider Demographics
NPI:1710651120
Name:MORTIMER, TASHA (LPCC)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:MORTIMER
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELLEMOOR LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-5647
Mailing Address - Country:US
Mailing Address - Phone:715-220-2629
Mailing Address - Fax:
Practice Address - Street 1:1050 CHINOE RD STE 203
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-6571
Practice Address - Country:US
Practice Address - Phone:859-554-0740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY272544101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health