Provider Demographics
NPI:1770643975
Name:MORTENSEN, LISA (MS ATC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MS ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 W 140 S
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-2062
Mailing Address - Country:US
Mailing Address - Phone:801-812-2736
Mailing Address - Fax:
Practice Address - Street 1:405 S 100 E STE 102
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-2751
Practice Address - Country:US
Practice Address - Phone:801-785-9991
Practice Address - Fax:801-785-9417
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6332468-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer