Provider Demographics
NPI:1720209240
Name:MORTENSEN, MICHELLE LEE (MT-BC, NMT)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:LEE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MT-BC, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WEST SEMINOLE ST.
Mailing Address - Street 2:
Mailing Address - City:DWIGHT
Mailing Address - State:IL
Mailing Address - Zip Code:60420-1151
Mailing Address - Country:US
Mailing Address - Phone:815-584-2246
Mailing Address - Fax:
Practice Address - Street 1:816 S. FIRST ST.
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356
Practice Address - Country:US
Practice Address - Phone:815-875-5848
Practice Address - Fax:815-875-5848
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL07735225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist