Provider Demographics
NPI:1821461146
Name:MORTENSON, SUSAN RAE (MA, LPC, CRC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:RAE
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:MA, LPC, CRC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:RAE
Other - Last Name:CASEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CASEY
Mailing Address - Street 1:4855 SW WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3460
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4855 SW WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3460
Practice Address - Country:US
Practice Address - Phone:503-813-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274147Medicaid