Provider Demographics
NPI:1851045561
Name:MORTENSEN, LISHA MARIE
Entity Type:Individual
Prefix:
First Name:LISHA MARIE
Middle Name:
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12760 S PARK AVE UNIT 363
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-3415
Mailing Address - Country:US
Mailing Address - Phone:801-443-7775
Mailing Address - Fax:801-447-0107
Practice Address - Street 1:12453 S 265 W STE B
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5420
Practice Address - Country:US
Practice Address - Phone:801-443-7775
Practice Address - Fax:801-447-0107
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12667850-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist