Provider Demographics
NPI:1780644310
Name:MORTENSEN, KRISTEN RAYBURN (MPT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RAYBURN
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 GARLINGTON RD STE A
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-5485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1310 GARLINGTON RD STE A
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-5485
Practice Address - Country:US
Practice Address - Phone:864-288-2998
Practice Address - Fax:864-288-3522
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4405225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1496Medicaid
SCTH1496Medicaid